TRANSFUSION SCIENCE
Annual SHOT Report 2024: laboratories in need of a lifeline
In its 2024 annual report, the Serious Hazards of Transfusion (SHOT) scheme shows evidence of a particularly challenging year for staff working in transfusion laboratories.
NM: Near miss Anti-D: Anti-D
immunoglobulin errors
IBCT: Incorrect blood component transfused
FAHR: Febrile, allergic and hyptotensive reactions
Delayed transfusion
HSE: Handling and storage errors
RBRP: Right blood right patient
TACO: Transfusion-associated circulatory overload
Avoidable transfusion
HTR: Haemolytic transfusion reactions
Non-TACO: Pulmonary complications of transfusion
Prothrombin complex concentrates (PCC)
Under or overtransfusion CS: Cell salvage UCT: Uncommon complications of transfusion
TTI: Transfusion-transmitted infection
PTP: Post-transfusion purpura
TAGvHD: Transfusion-associated graft-vs-host disease
00 14 51 44
35 31
20 19
0 0
0 100 100 Number 200 200 Fig 1. Categorisation of SHOT reports analysed in 2024 (n=3,998). 300 300 400 400 1500 500 188 170 278
312 311
359 354 1408 418
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. SHOT evaluates these data and provides resources to improve patient and transfusion safety through many channels.
This article provides a high-level overview of the Annual SHOT Report 2024, with a specific focus on laboratory practice. A breakdown of the Annual SHOT Report 2024 (assessing a total of 3,998 case reports), is shown in Figure 1. In total 83.1% (3,322/3,998) of reports
Error Not preventable Possibly preventable
were errors, which continue to account for over 80% of reports submitted to SHOT each year. Learning from these incidents allow SHOT to identify trends in transfusion safety, develop educational resources and promote 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. In response to recurring themes identified in successive Annual SHOT Reports and serial recommendations previously published by SHOT, a new document, SHOT Transfusion Safety Standards was published in July 2025. These safety standards were developed with input from key stakeholders and will replace yearly SHOT recommendations. The intention is to help drive improvement actions to minimise risks, maintain reliability, ensure effectiveness of transfusions, and optimise safety for everyone involved within transfusion. Several standards directly involve laboratory practice, such as staffing, information technology (IT), equipment and safety culture. A link to
OCTOBER 2025
WWW.PATHOLOGYINPRACTICE.COM
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