Laboratory incidents specialist Hema Mistry summarises the 2017 SHOT Annual Report, and looks at why the same errors continue to occur and how many of them could have been prevented.
The Serious Hazards of Transfusion (SHOT) scheme collects and analyses anonymised information reported in the UK about serious adverse reactions and other serious adverse events (SAE) related to blood transfusion, then makes recommendations to improve patient and transfusion safety. From 2015, SHOT Reports have included data for donor vigilance provided by the four UK Blood Services demonstrating the full range of haemovigilance from donor to recipient. This year SHOT celebrated 21 years with the release of its Annual Report. The breakdown of all reports analysed and included in the Annual SHOT Report 2017 (published on 12 July 2018) is as shown in Figure 1. The number of preventable errors remains high, with 85.5% in 2017 compared with 87.0% in 2016.
Key SHOT recommendations
Deaths, major morbidity and ABO-incompatible transfusions
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