Annual SHOT Report 2012

SHOT is affiliated to the Royal College of PathologistsThe investigation report produced some key findings: – Only one unit of blood should be removed from storage at any time – the nurse collecting took three units for three separate patients at the same time – The final administration check should always be conducted next to the patient by two registered nurses, and once all checks have been completed, the transfusion should be started immediately – the staff did not commence transfusion immediately after an initial check of the units, but placed the units on a table before picking them up again, so the final bedside check was not performed properly – Transfusion must only take place where there are enough staff available to monitor the patient and when the patient can readily be observed – a second nurse who had assisted in the checking procedures had returned to her ward, leaving one nurse in the day unit to administer and monitor three transfusions, including leaving the ward unsupervised while she went to collect further unit

Annual SHOT Report 2013

SHOT is affiliated to the Royal College of PathologistsThe current risks from blood and blood component transfusion in the UK remains small with a risk of death at 8.0 and risk of major morbidity 51.8 per 1,000,000 components issued. New strategies are required to reduce the level of error in the transfusion process. Checklists are very useful to ensure all the steps of a process have been completed and should be introduced for transfusion as recommended in 2011 (http://www.shotuk.org/resources/current-resources/ ). Any unexpected transfusion reactions must be promptly recognised and treated and continue to be reported. Appropriate local review of incidents including root cause analysis where indicated will help to identify systems problems which can be remedied. All staff involved in transfusion are reminded that they have a duty of care to report adverse events which potentially or actually affect patient safety

Annual SHOT Report 2011

SHOT is affiliated to the Royal College of PathologistsTransfusion of blood components in the UK remains remarkably safe, with the risk of death 0.0027 and risk of major morbidity 0.0396 per 1000 components issued respectively. However, the level of error in the transfusion process is a cause for concern, indicating the need for continued education, which should underpin competency assessment, and vigilance. Checklists are very useful to ensure all the steps of a process have been completed. Any unexpected transfusion reactions must be promptly recognised and treated and continue to be reported to ensure patient safety, particularly with the advent of new products and changing policies in relation to CMV screening. All staff involved in transfusion should remain aware that they have a duty of care to report adverse events which potentially or actually affect patient safety

Annual SHOT Report 2020

SHOT is affiliated to the Royal College of Pathologists. This report is produced by SHOT working with MHRAKey SHOT messages • Ensuring transfusion teams are well resourced: Clinical and laboratory teams can function optimally only if adequately staffed and well resourced. Healthcare leaders and management must ensure that staff have access to the correct information technology (IT) equipment and financial resources for safe and effective functioning • Addressing knowledge gaps, cognitive biases, and holistic training: Transfusion training with a thorough and relevant knowledge base in transfusion to all clinical and laboratory staff along with training in patient safety principles, understanding human factors and quality improvement approaches are essential. It is important that staff understand how cognitive biases contribute to poor decision making so that they can be mitigated appropriately • Patient safety culture: Fostering a strong and effective safety culture that is ‘just and learning’ is vital to ensure reduction in transfusion incidents and errors, thus directly improving patient safety • Standard operating procedures (SOP): SOP need to be simple, clear, easy to follow and explain the rationale for each step. This will then ensure staff are engaged and more likely to be compliant and follow the SOP • Learning from near misses: Reporting and investigating near misses helps identify and control risks before actual harm results, thus providing valuable opportunities to improve transfusion safety • Learning from the pandemic: The learning from the pandemic experiences should be captured in every organisation, by everyone in healthcare and used to improve patient safet

Annual SHOT Report 2021

SHOT is affiliated to the Royal College of Pathologists. This report is produced by SHOT working with MHRAPartnering with patients to enhance safety: Staff must ensure that they involve, engage and listen to patients as ‘partners’ in their own care, including transfusion support. Engaging patients, their families, and carers as ‘safety partners’ helps co-create safer systems, identify, and rectify preventable adverse events. Investing in safety - well-resourced systems with safe staffing levels: Healthcare leaders must ensure that systems are designed to support safe transfusion practice and allocate adequate resources in clinical and laboratory areas to ensure safe staffing levels, staff training in technical and non-technical skills and appropriate equipment, including IT systems. Just and learning safety culture: All healthcare leaders must promote a just, learning safety culture with a collective, inclusive, and compassionate leadership. Effective leaders must ensure staff have: access to adequate training, mentorship, and support. All staff in clinical and laboratory areas have a responsibility to speak up in case of any concerns and help embed the safety culture in teams

Annual SHOT Report 2018

SHOT is affiliated to the Royal College of PathologistsAll NHS organisations must move away from a blame culture towards a just and learning culture. All clinical and laboratory staff should be encouraged to become familiar with human factors and ergonomics concepts. All transfusion decisions must be made after carefully assessing the risks and benefits of transfusion therapy. Collaboration and co-ordination among staff is vital

Annual SHOT Report 2015

SHOT is affiliated to the Royal College of PathologistsBe WARM: Work Accurately and Reduce Mistakes 1. Use a TACO checklist 2. Use a bedside checklist TACO Checklist Red Cell Transfusion for Non-Bleeding Patients. Human factors in hospital practice. Be safe! Use the bedside checklist. • Review the need for transfusion (do the benefits outweigh the risks)? • Can the transfusion be safely deferred until the issue can be investigated, treated or resolved? • Consider body weight dosing for red cells (especially if low body weight) • Transfuse one unit (red cells) and review symptoms of anaemia • Measure the fluid balance • Consider giving a prophylactic diuretic • Monitor the vital signs closely, including oxygen saturatio

Annual SHOT Report 2017

SHOT is affiliated to the Royal College of PathologistsTraining in ABO and D blood group principles is essential for all laboratory nd clinical staff with any responsibility for the transfusion process. This should form part of the competency assessments. All available information technology (IT) systems to support transfusion practice should be considered and these systems implemented to their full functionality. Electronic blood management systems should be considered in all clinical settings where transfusion takes place. This is no longer an innovative approach to safe transfusion practice, it is the standard that all should aim for. A formal pre-transfusion risk assessment for transfusion-associated circulatory overload (TACO) should be undertaken whenever possible, as TACO is the most commonly reported cause of transfusionrelated mortality and major morbidity (repeat from last year

Annual SHOT Report 2016

SHOT is affiliated to the Royal College of PathologistsABO-incompatible transfusions are the tip of the iceberg; they most commonly result from failure to identify the patient at the time of blood sampling (wrong blood in tube) or administration to the wrong patient. Pulmonary complications, particularly transfusion-associated circulatory overload (TACO), cause the most deaths and major morbidity. Delayed transfusions are an important cause of death, 25/115 (21.7%) 2010 to 2016. Many errors in transfusion, some with serious clinical consequences, relate to poor communication between teams, shifts and interfaces. The infrastructure needs improvement to facilitate exchange of results within and between hospitals. IT errors contributed to 1 in 5 SAE reported. IT is not infallible, it makes transfusion practice safer by helping to control and support the task, but does not replace knowledge about the task

Annual SHOT Report 2014

SHOT is affiliated to the Royal College of PathologistsBlood and blood component transfusion in the UK is very safe with a small number of adverse incidents in relation to the number of components issued and transfused. In 2014 (January to December) the total number of reports made to SHOT was 3668 and 3017 were analysed for this Annual Report (others were incomplete or withdrawn). The total number of reports made to the Medicines and Healthcare products Regulatory Agency (MHRA) was 1110 of which 764 were serious adverse events (errors in 97.8%) and 346 were serious adverse reactions. The proportion of SHOT reports where errors were the underlying cause was similar to 2013, 77.8% (2346 reports). Acute transfusion reactions (allergic/febrile) were the most common pathological reactions. The cumulative data (18 years) can be viewed on the website www.shotuk.org