TRANSFUSION SCIENCE TACO Delayed transfusion Pulmonary non-TACO HTR PCC UCT Overtransfusion 1 1 1 0 0 5 5 10 10 15 15 Number
Fig 2. Deaths related to transfusion (with imputability) reported in 2024. (NB imputability refers to the degree of certainty the event was caused by the transfusion.)
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the SHOT Transfusion Safety Standards is included in the resources section of this article.
Deaths, major morbidity and ABO–incompatible transfusions In 2024, there were 59 deaths related to transfusion, which marks a steep increase from the 38 deaths in 2023 (Fig 2). The SHOT figures for 2024 translate to a risk of death in the UK of 1 in 37,000 components issued and the risk of serious harm is 1 in 11,500 components issued.
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Transfusion-associated circulatory overload (TACO) contributed to most deaths (29/59), followed by delays (18/59) and pulmonary non-TACO cases (4/59). Of note, there were three deaths related to haemolytic transfusion reactions. There were four ABO-incompatible (ABOi) transfusions in 2024. Most (3/4) were related to group O fresh frozen plasma (FFP) and solvent detergent-FFP (SD-FFP) being transfused to non- group O patients. All cases involved plasma components, two of group
Case study 1 Staffing pressures impacting training
A BMS 1 who was lone working in blood transfusion over a weekend shift issued two M-negative red cell units to a patient with anti-M. The BMS had not completed testing to exclude anti-S from the antibody identification panels at this point but did not issue S-negative units as per local policy. Further investigation carried out on the following day indicated that anti-S could have been excluded using additional extended panel cells that were available in the laboratory. During the event review, the BMS 1’s competencies showed gaps in antibody identification, including the relevance of heterozygous and homozygous panel cells, and selection of red cells when a red cell antibody is present. This training need had been identified six months previously, but no action had been undertaken to rectify. The responsibility for training junior staff members had recently rotated and may have contributed to this. During local investigation, BMS 1 stated that they had not been signed off as able to perform the task unsupervised, and that the transfusion laboratory manager had taken responsibility for these training gaps so that BMS could be expedited on to the shift rota. Local investigation also stated that other haematology staff were only being trained in transfusion emergency procedures, such as
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management of major haemorrhage activations, before being allowed on shift. Due to extreme staffing pressures, which had been raised on the local risk register, a corrective action was implemented regarding out-of-hours working. This stipulated that staff will be allowed on the 24/7 shift rota with selected competencies completed, with support of a fully trained staff member being available for queries (who may be working in another department). n SHOT insight 1: Whilst staffing pressures persist, actions undertaken to provide cover for shifts must also include the impact on patient safety. Such a solution may leave vulnerabilities for staff members whose decision making may be incomplete due to unfinished training. In these circumstances, staff members may not think to seek help as they may not be aware of the full impact of decisions made.
n SHOT insight 2: Further review of this case showed signals of blame culture prevalent within the team, as the local investigation assigned responsibility of the event to BMS 1. It stated they should not have undertaken tasks they were not signed off on, even though they had been required to participate in lone working without a full competency assessment.
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Definite/certain Likely/probable Possible
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O FFP to group A patients, and one case of group O SD-FFP to a group B patient. According to manufacturer’s instructions, SD-FFP should not be used across blood groups (emc, 2025). IT impacted all laboratory ABOi, with two cases having a note within the laboratory information management system (LIMS) to use group A FFP (as the patients had been temporarily assigned group O in an emergency). These alerts were not automatically generated and therefore not viewed or actioned. In the third case there was lack of functionality with the IT system to prevent the incompatible transfusion taking place. The remaining case involved group
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A red cells being connected to a group O patient prior to identification checks taking place. Further details can be found in the Annual SHOT Report 2024.
Serious adverse reactions Adverse reactions were reported in a total of 677 cases, with most reported as febrile, allergic and hypotensive reactions (354/677, 52.3%). A total of 51 haemolytic transfusion reactions (HTR) were reported in 2024; 16 acute (AHTR), 21 delayed (DHTR) and 14 cases of hyperhaemolysis. Three deaths related to HTR occurred in patients with sickle cell disorder (SCD) (two with imputability 2 – probable/likely and one with imputability 1 – possible).
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The most implicated antibodies in AHTR were anti-Jka
, anti-E, anti-S, pan reactive auto antibodies and antibodies 35
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