The Serious Hazards of Transfusion (SHOT) report for 2013 provides the latest analysis of adverse events in blood transfusion, as well as key recommendations. A summary of the full report, which is available on the SHOT website, is reproduced below by kind permission.
The 17th Annual SHOT Report summarises data received between January and December 2013. Participation continues to be excellent at 99.5% of NHS Trusts and Health Boards across the UK. The total number of reports submitted for 2013 was similar to 2012 at 3568, of which 2751 have been analysed for this year’s report. The total includes ‘near miss’ (n=996) and ‘right blood right patient’ (n=184), events that by definition caused no harm. Most organisations make between 1 and 30 reports (84.9%) and a small number make more than 50 (7.0%).
Overall, errors, or human factors, played a part in 77.6% of reports including nine ABO incompatible red cell transfusions which contributed to death in one patient and major morbidity in a further three. Figure 1 shows the cumulative data for 17 years. Acute transfusion reactions remain the most common unpredictable incidents (allergic/hypotensive/severe febrile: 320 in 2013). There were no transfusion- transmitted bacterial infections reported in the past four years, and no new viral transmissions in 2013.
ABO incompatible red cell transfusions
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