Safety Alert

Serious Hazards of Transfusion: Safety Alert and Resources

Resources and learning from Serious Hazards of Transfusion (SHOT), the UK's independent professionally-led haemovigilance scheme.

By meganpeng · January 24, 2022

Serious Hazards of Transfusion (SHOT) is the UK’s independent, professionally-led haemovigilance scheme. Since 1996, SHOT has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations involved in the transfusion of blood and blood components in the UK.

Working collaboratively with the Medicines and Healthcare Products Regulatory Agency (MHRA), SHOT collects reports of serious adverse reactions and serious adverse events relating to transfusion of blood components and some blood products, identifying areas for improvement and providing recommendations for safer transfusion practices.

SHOT safety alert

Transfusion delays are preventable, and the urgent provision of blood components and/or blood products is vital for life threatening bleeding and severe anaemia. Serious harm related to delayed transfusion have been reported to SHOT with the number of incidents increasing each year.

A safety alert has been published by SHOT following review of delayed transfusions reported to SHOT between 2010-2020. This is the first alert to have been issued from SHOT, and details can be found on the MHRA Central Alerting System here.

SHOT resources

Three quarters of all incidents reported to SHOT are related to errors, and patient safety incidents and errors in transfusion can lead to fatal outcomes. Effective investigation of these incidents is essential to optimise learning and prevent further incidents occurring.

In 2021, SHOT incorporated and amended The Yorkshire Contributory Factors Framework into a Human Factors Investigation Tool (HFIT). This tool aims to optimise learning and address causes of patient safety incidents by supporting SHOT, clinicians, risk managers and patient safety officers to identify contributory factors that can help prevent future adverse incidents. Visit the Human Factors section on the SHOT website for more information and to download the HFIT Training Package.

More resources can also be found on the SHOT website, including the ‘SHOTcasts’ podcast series, ‘SHOT Bites’ information leaflets, educational videos and webinar recordings. Watch the ‘Paediatric SHOT’ video below, in which SHOT paediatric experts explain how paediatric haemovigilance reports differ from those in adults, and the key messages from the last 10 years of paediatric SHOT reporting: