TRANSFUSION SCIENCE
Sample receipt and reigistration
Testing Component selection
Component availability
Handling and storage Component labelling
Miscellaneous 0 0
IBCT-WCT IBCT-SRNM HSE
RBRP Delayed
Avoidable transfusion
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Under or over transfusion
IBCT-WCT: Incorrect blood component transfused - wrong component transfused; IBCT-SRNM: IBCT-specific requirements not met; HSE: Handling and storage errors; RBRP: Right blood right patient; PCC: Prothrombin complex concentrates; lg: immunoglobulin. Note: numbers <3 are too small to be annotated on the figure.
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5 15 14 40 25
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4 3 9 3 31 14 10 95 46 62 18 13 24 60
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n Factors contributing to laboratory errors
Fig 3. Laboratory errors in 2024, classified by the transfusion step where the primary error occurred (n=601).
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to low-incidence antigens (2/16 each). In DHTR the most implicated antibody was anti-Jka
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SHOT data shows that patients are generally treated with a combination of intravenous immunoglobulin (IVIg), steroids and erythropoietin (EPO). It is important to note that combinations of different treatments are often used to
(8/21). 50
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manage hyperhaemolysis, with no clear trends.
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Focus on laboratory data In 2024, laboratory errors have increased by 12% (from 535 in 2023, to 601). The largest increase occurred in the delayed transfusion category which has more than doubled (from 56 in 2023, to 120). Near miss reports have also increased from 207 in 2023, to 268. There were three deaths,
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and three cases of major morbidity (as specified in SHOT reporting definitions, available at
www.shotuk. org/reporting/incident/ definitions/) related to errors within the laboratory. All were due to delays in transfusion and are discussed later in this article. The largest proportion
In July 2025, SHOT released the SHOT Transfusion Safety Standards document, which covers various aspects of patient care and staff wellbeing.
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of reports resulted in incorrect blood component transfused-specific requirements not met (IBCT-SRNM) events, 160/601 (26.6%), followed by delayed transfusions, 120/601 (20.0%). The primary error mostly occurred during laboratory testing, 206/601 (34.3%), component selection, 113/601 (18.8%) and component availability steps, 101/601 (16.8%) (Fig 3).
A mismatch between workload and staff capacity at the time of the incident was noted in 112/601 (18.6%) of laboratory reports. This is an increase from the 72/535 (13.5%) identified in 2023. The Infected Blood Inquiry (IBI) recommendation 7C states: ‘Transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions.’ Transfusion laboratories are still struggling to obtain adequate funding for staffing provision, and to recruit and retain staff with an appropriate level of knowledge and experience. There has also been an increase in the number of reports which stated the member of staff was lone working when the error occurred, 198/601 (32.9%) in 2024, up from 160/535 (29.9%) in 2023. A total of 213/513 (41.5%) reports stated that the error occurred outside of normal working hours. (This figure does not include data for anti-D immunoglobulin [Ig] related incidents as this question is not requested in the anti-D Ig data set.) Furthermore, in 117/601 (19.5%) reports, the staff member was covering more than one laboratory department at the time of the event. This trend could also signify that there
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is an increased workload outside of routine hours, as outpatient facilities are being provided into the evenings and at the weekend more often. Considerations should be made to increasing staff outside of normal working hours if workload exceeds the amount which is acceptable for one individual during routine hours. Actions should also be taken to minimise work that needs to be undertaken outside routine hours when an individual is working by themselves. Assessing and redistributing the workload throughout the day
The proportion of errors year on year remains consistent, therefore it is essential systematic barriers to safe practice are identified and improvements made
OCTOBER 2025
WWW.PATHOLOGYINPRACTICE.COM
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