The 2022 Annual Report from the Serious Hazards of Transfusion (SHOT) scheme has been published recently, once again collecting and analysing anonymised information on serious adverse events and reactions in blood transfusion from all healthcare organisations. Here SHOT Laboratory Incident Specialist Victoria Tuckley summarises its key points and recommendations.
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 United Kingdom. From this data SHOT makes recommendations to improve patient and transfusion safety. A breakdown of the 2022 Annual SHOT Report1 (assessing a total of 3499 case reports), is shown in Figure 1.
(Note: please download the PDF version of this article to see all the figures)
In total 2908/3499 (83.1%) reports were errors, which continue to account for over 80% of reports submitted each year. Learning from these incidents allow SHOT to identify trends in transfusion errors, develop educational resources and issue recommendations for safer practice. The proportion of errors year on year remains consistent, and taking a holistic approach may help to reduce these. To understand the source of transfusion errors, investigations should look further than the individual, and a system-based approach should be employed.
Key SHOT messages
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