SHOT 2019 data: why be reactive with safety when we can be proactive

Serious Hazards of Transfusion (SHOT) works collaboratively with the Medicines and Healthcare products Regulatory Agency to oversee haemovigilance throughout the UK, collecting and analysing anonymised information relating to serious adverse reactions (SAR) and serious adverse events (SAE) of blood transfusion reported in the UK. SHOT then makes recommendations to improve patient and transfusion safety in the Annual SHOT Report. A breakdown of the 2019 Annual SHOT Report (assessing a total of 3397 case reports) is shown in Figure 1.

          This year’s Annual SHOT Report focuses on taking an holistic view of patient safety, building on the concepts of Safety-I and Safety-II, and stressing the importance of learning from excellent care as well as acting on errors (Fig 2).¹ A new chapter was introduced ‘Acknowledging Continuing Excellence’ to highlight the importance of recognising incidences of excellence in healthcare and using this to improve our standard care. The concept of cognitive biases (cognitive short cuts to aid decision-making) was also highlighted, and how these must be considered within our processes.

Key SHOT recommendations