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

SHOT laboratory incident specialist Victoria Tuckley summarises the 2019 Annual Report, and highlights why it is vital to look beyond the individual, their actions and the assignment of blame or deficiency for improvements in safety to be made.

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

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Upcoming Events

USCAP 113th Annual Meeting

Baltimore Convention Center, Baltimore, Maryland, USA
23-28 March, 2024

Pathology Horizons 2024

MacDonald Bath Spa Hotel, Bath
18-20 April, 2024

Diagnostics North East Conference 2024

The Catalyst, Newcastle upon Tyne
19 April, 2024

ECCMID 2024 - European Congress of Clinical Microbiology and Infectious Diseases

Fira Gran Via, 08038 Barcelona, Spain
27-30 April 2024

British Society for Microbial Technology Annual Microbiology Conference

UK Health Security Agency, Colindale, London
2 May 2024

EQA Reports: Interpreting Key Information & Troubleshooting Tips

ONLINE - Zoom
Thursday 16th May 2024

Access the latest issue of Pathology In Practice on your mobile device together with an archive of back issues.

Download the FREE Pathology In Practice app from your device's App store

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