Incident investigation in blood transfusion practice: a review and update

Serious Hazards of Transfusion (SHOT) is the UK’s independent haemovigilance system, collecting and analysing anonymised information on adverse events and reactions in blood transfusion and, where risks and problems are identified, producing recommendations to improve patient safety. Collating the information from events from across the UK gives SHOT a larger number of reports to trend and produce recommendations for safer practice that could not be possible with smaller numbers of events at the individual organisational level. When we improve our practices, this may in turn lead to a reduction in errors and ultimately make the system safer for our patients.

                The United Kingdom Accreditation Service (UKAS)¹ and the Blood Safety and Quality Regulations (BSQR) Good Practice Guide (GPG)² require laboratories to detail the identification and control of adverse events as non-conformances and requires the corrective and preventative actions (CAPA) to be clearly detailed in a non-conformance (NC) report. Using a quality management system to record NCs also allows the investigator to trend adverse events and incorporate continuous quality improvement.

                The 2020 Annual SHOT Report ³ outlined that the number of errors in transfusion practice account for over 80% of reports submitted each year, and learning from these incidents allows SHOT to identify recommendations for safer systems (Fig 1).