TRANSFUSION SCIENCE
The SHOT Report 2023: Can opportunity follow learning from adversity?
The Serious Hazards of Transfusion (SHOT) scheme has recently published its Annual Report, collecting and analysing information on serious adverse events in blood transfusion within the UK. SHOT Laboratory Incident Specialist Victoria Tuckley presents a summary of its key points.
NM: Near miss Anti-D: Anti-D
immunoglobulin errors
IBCT: Incorrect blood component transfused
HSE: Handling and storage errors
FAHR: Febrile, allergic and hyptotensive reactions
RBRP: Right blood right patient ADU: Delayed transfusion
TACO: Transfusion-associated circulatory overload
ADU: Avoidable transfusion
HTR: Haemolytic transfusion reactions
Non-TACO: Pulmonary complications of transfusion
CS: Cell salvage UCT: Uncommon
complications of transfusion
ADU: Prothrombin complex concentrates (PCC)
ADU: Under or overtransfusion
PTP: Post-transfusion purpura TTI: Transfusion-transmitted
infection
TAGvHD: Transfusion-associated graft-vs-host disease
00 33
26 24 23 20
1 4
0 100 100 Number 200 200 Fig 1. Categorisation of SHOT reports analysed in 2023. n=3,833.
WWW.PATHOLOGYINPRACTICE.COM FEBRUARY 2025 300 300 400 400 1500 500 52 127 Error Not preventable Possibly preventable
Deaths, major morbidity and ABO–incompatible transfusions In 2023, there were 38 deaths related to transfusion. One death was definitely due to the transfusion (imputability 3), due to failure to administer prothrombin complex concentrate to a bleeding patient who was taking warfarin and had an international normalised ratio so high it was unrecordable (Fig 2). The SHOT figures for 2023 translate to a risk of death in the UK of 1 in 58,000 components issued, with a risk of serious harm of 1 in 11,000 components issued. Transfusion-associated circulatory overload (TACO) contributed to most deaths (15/38, 39.5%), followed by delays (9/38, 23.7%) and pulmonary non-TACO
17 172 259 212 356 342 336 1420 425
The Serious Hazards of Transfusion (SHOT) haemovigilance 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. From these data SHOT makes recommendations to improve patient and transfusion safety. This article provides a high-level overview of the Annual SHOT Report 2023, with a specific focus on laboratory practice. A breakdown of the Annual SHOT Report 2023 (assessing a total of 3,833 case reports), is shown in Figure 1. In total 3,184/3,833 (83.1%) reports
were errors, which continue to account for over 80% of reports submitted to SHOT each year. Learning from these incidents allows SHOT to identify trends in transfusion safety, develop educational resources and issue recommendations for safer practice. The proportion of errors year-on-year remains consistent; therefore it is essential systematic barriers to safe practice are identified and improvements made.
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