Patient safety
Understanding serious transfusion hazards
The latest Annual Report from the Serious Hazards of Transfusion (SHOT) scheme has been published, once again collecting and analysing anonymised information on serious adverse events and reactions in blood transfusion from all healthcare organisations. Victoria Tuckley and Simon Carter-Graham summarise its key points and recommendations, with the aim of learning lessons and improving patient safety.
The Serious Hazards of Transfusion (SHOT) 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 (UK). From this data, SHOT makes recommendations to improve patient and transfusion safety. A breakdown of the 2022 Annual SHOT Report1
(assessing a total of 3499
case reports) is shown in Figure 1. In total, 2908/3499 (83.1%) reports were
errors, which continue to account for over 80% of reports submitted each year. Learning from these incidents allow SHOT to identify trends in
NM: Near miss Anti-D: Anti-D
immunoglobulin errors
IBCT: Incorrect blood component transfused
FAHR: Febrile, allergic and hyptotensive reactions
HSE: Handling and storage errors
RBRP: Right blood right patient ADU: Delayed transfusion
TACO: Transfusion-associated circulatory overload
ADU: Avoidable transfusion Non-TACO: Pulmonary
complications of transfusion HTR: Haemolytic
transfusion reactions
ADU: Prothrombin complex concentrates (PCC)
CS: Cell salvage ADU: Over or
undertransfusion UCT: Uncommon
complications of transfusion
PTP: Post-transfusion purpura TTI: Transfusion-transmitted
infection
TAGvHD: Transfusion-associated graft-vs-host disease
0
21 20 18 13
1 2
0
Fig 1. Categorisation of reports analysed in 2022. 0
50 50 100 100 150 150 Number 200 200 250 250 300 300 350 350 400 121 52 49 160 272 264 205 296 294
Key SHOT messages l Safe staffing: Clinical and laboratory teams can function optimally only if they are adequately staffed and well resourced. Staffing challenges in both clinical and
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transfusion safety, develop educational resources and issue recommendations for safer practice. The proportion of errors year on year remains consistent, and taking a holistic approach may help to reduce these. To understand the source of transfusion errors, investigations should look further than the individual, and a system-based approach should be employed.
laboratory areas are commonly cited as contributory in transfusion incidents and must be addressed urgently. Adequate numbers of appropriately trained staff must be available to ensure safe transfusions; there should be contingency planning for staffing levels below a minimum level and for times of high workload.
l Well-resourced systems: Healthcare leaders and management must ensure that staff have access to the correct information technology (IT) equipment which is fit for purpose. Adequate financial resources are a must for safe and effective functioning of teams.
l Addressing knowledge gaps, cognitive biases, and holistic training: Providing transfusion training with a thorough and relevant knowledge base in transfusion to all clinical and laboratory staff along with training in patient safety principles, understanding human factors and quality improvement approaches is essential. It is important that staff understand how cognitive biases contribute to poor decision making so that these can be mitigated appropriately.
l Patient safety culture: Fostering a strong and effective safety culture that is ‘just and learning’ is vital to ensure a reduction in transfusion incidents and errors, thus directly improving patient safety.
Error Not preventable Possibly preventable
l Addressing transfusion delays: Avoidable transfusion delays continue to contribute to patient deaths and measures recommended in the SHOT CAS alert2 to address these.
must be implemented
l Addressing transfusion errors: Errors continue to be the source of most SHOT reports (83.1%). While transfusions are largely safe, errors can result in patient harm. Many of these are caused by poor communication and distraction. These must be investigated
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