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The SHOT Report 2023: Can opportunity follow learning from adversity?

The Serious Hazards of Transfusion (SHOT) scheme has recently published its Annual Report, collecting and analysing information on serious adverse events in blood transfusion within the UK. SHOT Laboratory Incident Specialist Victoria Tuckley presents a summary of its key points.

The Serious Hazards of Transfusion (SHOT) haemovigilance 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 these data SHOT makes recommendations to improve patient and transfusion safety.  

This article provides a high-level overview of the Annual SHOT Report 2023, with a specific focus on laboratory practice. A breakdown of the Annual SHOT Report 2023 (assessing a total of 3,833 case reports), is shown in Figure 1.

In total 3,184/3,833 (83.1%) reports were errors, which continue to account for over 80% of reports submitted to SHOT each year. Learning from these incidents allows SHOT to identify trends in transfusion safety, develop educational resources and issue recommendations for safer practice. The proportion of errors year-on-year remains consistent; therefore it is essential systematic barriers to safe practice are identified and improvements made.

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