SHOT–A Voluntary System for the Reporting of Serious Hazards of Transfusion in the UK

Abstract

SUMMARy Background: From 1996–2001 the SHOT scheme has collected a powerful body of data on serious transfusion complications in the UK from which to make firm recommendations for improvements in transfusion safety. The UK Blood Services issue approximately 3.5 million blood components annually. Results: With 413 eligible hospitals on the scheme, by year five, participation was running at 92%. Of 1,148 fully analyzed reports there were 699 (61%) “wrong blood” incidents. Of these, 161 were ABO incompatible transfusions leading to 11 deaths and 60 cases of major morbidity and 73 were RhD incompatible leading to potential RhD sensitization in 17 young females. Multiple errors occurred in 49% of cases. 55% of errors involved mis‐identification at the point of collection from the hospital storage site and/or bedside administration, whilst laboratories and prescription/sampling/request errors contributed 28% and <13% respectively. Immune complications comprised 35.7% of reports. 70 cases of possible TRALI over 5 years resulted in 49 cases of major morbidity and up to 20 deaths possibly related to transfusion. Transfusion‐transmitted infection (TTI) comprised < 3% of reports but of 39 confirmed TTIs 25 were bacterial contamination incidents (21 platelets, 4 red cells) resulting in 6 deaths (5 platelets; one red cells). Recommendations:“Wrong blood” incidents are avoidable errors. Efforts should be directed at developing computerized bedside identification systems to reduce human error. These can be linked to secure systems to reduce errors at the point of collection from storage and are also applicable in the drugs administration setting. Options to reduce the incidence of TRALI should be explored. Possible strategies to reduce bacterial contamination should be given appropriate priority.