TRANSFUSION SCIENCE


n Impact of the laboratory delays There were three patient deaths due to laboratory delays in 2024. This is an increase from previous years, as between the years 2019-2023 there were three deaths in total reported to SHOT related to laboratory errors. One death was probably related to the delay in transfusion (imputability 2). In this case there was a delay in releasing blood components for a neonate with suspected disseminated intravascular coagulation (DIC). Suitable blood components were available, but they were not issued in a timely manner. This case highlights the importance of understanding the suitability of alternative solutions where the appropriate blood components are not available to prevent delays and patients’ harm. Two deaths were possibly related to the delay of transfusion (imputability 1), both occurred during MH. In one case, there was a two-hour delay in providing FFP due to miscommunication between the laboratory and the clinical team, and a plasma thawer malfunction. This occurred during lone-working hours covered by an inexperienced BMS. The second case involved challenges in obtaining blood components for a patient having a cardiac arrest. There were three cases of major


morbidity, all as a consequence of blood components not being available in a timely manner during MH. These involved miscommunication and IT equipment failure.


Although the majority of delays had mainly no adverse clinical impact (114/120, 95%), there were eight cases where the delay in provision of blood components led to further bleeding or delay in obtaining haemostatic control that were not captured under major morbidity criteria. In 65/120 (54.2%) cases, the delays resulted in procedures or interventions being cancelled, re- scheduled or the patient having to return to the hospital on a different day for the transfusion.


Acknowledging continuing excellence (ACE) Despite numerous challenges related to workload, training and culture, laboratory staff are working tirelessly to provide support to patients. There were two ACE cases reported in 2024 which illustrate excellent communication, collaboration and focus on patient safety by transfusion laboratory staff. One such case is detailed in this article as Case study 3.


Conclusions The 2024 data reflects a particularly challenging year for staff working in transfusion laboratories. Factors which


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Case study 3 Whole-team communication in advance of surgery


Blood was successfully provided for a patient with sickle cell disorder and complex transfusion requirements/history (including hyperhaemolysis and multiple red-cell antibodies) undergoing surgery on a remote site. There was good communication between the surgical team, blood transfusion laboratory team, reference laboratory and clinical haematology to ensure availability of suitable units. Multi-disciplinary team meetings occurred via online video conferencing. Blood was delivered successfully and senior staff from the transfusion laboratory team remotely joined the World Health Organization (WHO) surgical checklist meeting to answer questions and concerns from the surgical team in theatre that day. The presence of the laboratory team at the meeting allowed information to be provided regarding component availability and confirmation of the plan for potential massive haemorrhage, which reassured the surgical team. This was the first time the laboratory staff had joined the WHO checklist meeting and provided good communication in a complex case. Learning from this case was shared via internal excellence reporting systems.


have been previously highlighted such as insufficient funding, staffing, knowledge and culture, persist and seem to be worsening. These have been compounded by issues such as cyberattacks and an overall increase in organisational pressures within the NHS. Worsening patient impact is now evident and is reflected in the steep rise in laboratory delays. Meaningful intervention is needed from senior hospital management, leadership teams and political leaders to improve working conditions within laboratories and to retain staff within this vital profession.


SHOT would once again like to extend its gratitude to transfusion staff for their tireless work and commitment to patient care. Without rapid intervention it may be possible that this caring workforce may feel more de-valued, lose momentum and the limited occurrences of slips and gaps in care may ultimately turn into a landslide. SHOT has observed and highlighted that breaking point was being approached, it may now have been passed. To enable the protection and safe care of patients in the UK, transfusion laboratories are in need of an urgent lifeline.


Further resources n For a more detailed analysis, visit the SHOT


website to download the full 2024 Annual SHOT Report and Summary. www.shotuk. org/shot-reports/annual-shot-report-2024/ or download the free SHOT App (search SHOT UK in app and play stores).


n SHOT Transfusion Safety Standards is available at www.shotuk.org/transfusion- safety/transfusion-safety-standards/


n The Infected Blood Inquiry report (2024) is OCTOBER 2025 WWW.PATHOLOGYINPRACTICE.COM


available at www.infectedbloodinquiry.org. uk/reports/inquiry-report


n Abbreviated UKTLC standards, UKTLC survey 2022 and SHOT and UKTLC culture survey 2023 are available at www.shotuk. org/resources/current-resources/uktlc/


n The SHOT UK Collaborative Reviewing and reforming IT Processes in Transfusion (SCRIPT): aiming to improve transfusion safety through improved IT systems and practices, is available at www.shotuk.org/ script/


n Electronic medicines compendium (EMC), 2025. octaplasLG solution for infusion, is available at: www.medicines.org.uk/emc/ product/4171/smpc#gref


SHOT Office


Manchester Blood Centre, Plymouth Grove, Manchester, M13 9LL


+44 (0) 161 423 4208 shot@nhsbt.nhs.uk www.shotuk.org


The case studies included are from the Annual SHOT Reports and the details are as provided to SHOT by reporters. All reports are anonymised and SHOT relies on reporters submitting correct and accurate information. SHOT does not accept responsibility for any inaccuracies which may arise from incorrect information being submitted. The cases are shared only to promote the learning from the incidents reported and improve transfusion safety.


The SHOT team acknowledge and


appreciate the valuable contributions of haemovigilance reporters across UK and members of the SHOT Steering Group and Working Expert Group. The SHOT Privacy Notice can be found at www.shotuk.org/ privacy/.


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