SHOT laboratory incident specialist Victoria Tuckley summarises the 2018 Annual Report, and highlights how to create safer transfusion practices, a more satisfactory working environment and improved patient safety.
The Serious Hazards of Transfusion (SHOT) scheme collects and analyses anonymised information relating to serious adverse reactions (SAR) and serious adverse events (SAE) of blood transfusion reported in the UK. It then makes recommendations to improve patient and transfusion safety. A breakdown of the 2018 Annual SHOT Report (assessing a total of 3326 case reports) is shown in Figure 1.
Key SHOT recommendations
All National Health Service (NHS) organisations must move away from a blame culture and towards a just and learning culture. This is vital to ensure that NHS organisations recognise and deal with people in a just way, acknowledging through learning to support the changes required when people make errors.
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