SHOT (Serious Hazards Of Transfusion) has published its new Transfusion Safety Standards, covering various aspects of patient care and staff wellbeing.
The new document has been developed with the aim of driving continuous improvement, safety, and resilience across healthcare. The intention and requirements/criteria for each are also provided. The SHOT Transfusion Safety Standards are also provided with accompanying resources, which include a timeline and a frequently asked questions document, with further documents to follow.
The SHOT Transfusion Safety Standards have been produced to promote and ensure safe, effective transfusions by identifying risks, implementing strategies that create a safer environment for everyone involved, contributing to better patient outcomes, staff wellbeing and overall system safety. The new Standards cover eight key areas - from governance and haemovigilance to staff training, IT systems, and patient involvement.
SHOT is the UK’s independent, professionally-led haemovigilance scheme analysing transfusion errors and reactions submitted annually since 1996 to identify areas for improvement to optimise safety. Haemovigilance reporting and learning from reports submitted contribute to improving patient safety. These reports provide a mechanism to identify risks so that all healthcare organisations can implement interventions to reduce these.
Serial Annual SHOT Reports indicate a worrying trend with more than 80% of reports related to avoidable errors. Recurring themes in analysed incidents include:
- Staffing issues, with shortages and mismatches with workload, inadequate skill mix, staff retention and recruitment challenges
- Gaps in staff knowledge with no protected training time, accelerated/abbreviated training programmes, poor awareness of the importance and application of human factors
- Inadequately resourced systems – lack of equipment or not fit for purpose
- IT issues: poor implementation, suboptimal staff training, no access to subject matter experts, overreliance on IT, complacency with alert fatigue/warning flags not heeded
- Poor communication within and between teams, especially during handovers
- Failure to listen to patients and families with missed opportunities for engagement
- Ineffective leadership and management, gaps in governance and suboptimal safety culture.
To address risks and problems identified, SHOT has been producing recommendations to improve patient safety which are in the annual reports. Prioritisation and implementation of recommendations have been left to individual healthcare organisations, both NHS and independent ones. With limited resources and ongoing challenges, while some recommendations relating to immediate patient safety risks may be implemented, it remains variable with a lack of sustained long-term change and similar themes continuing to be evident in reports analysed year on year. Haemovigilance is an ongoing exercise, and while SHOT monitor the impact and extent of implementation of these recommendations, there is no effector arm for SHOT. Lack of effective implementation of these recommendations, clashing priorities and worsening healthcare challenges post pandemic means that the gaps identified and the recommendations to address them continue to be the same year on year.
The SHOT Transfusion Safety Standards have been produced to address the recurring trends identified from the submitted reports and to embed a proactive approach to enhance safety. Additional drivers for developing these safety standards include recommendations from the Infected Blood Inquiry report, Lord Darzi’s report from an independent investigation of the NHS in England and the Health Services Safety Investigations Body report released in September 2024 ‘Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare’. Transfusion safety standards are intended to drive improvement actions to minimise risks, maintain reliability, ensure effectiveness of transfusions and optimise safety for all.
These SHOT Transfusion Safety Standards do not replace, but complement other regulatory or best practice recommendations. These standards provide a framework for peer review/self-assessment, compliance check by regulatory organisations and/or national oversight.
The new Standards are available on the SHOT website: www.shotuk.org/transfusion-safety/transfusion-safety-standards/.