Incident investigation in blood transfusion

Serious Hazards of Transfusion (SHOT) is the UK’s independent haemovigilance system, collecting and analysing anonymised information on adverse events and reactions in blood transfusion. Where risks and problems are identified, SHOT produce recommendations to improve transfusion safety which are published in an annual report. Collating the information from events across the UK gives SHOT a larger number of reports to trend and produce recommendations for safer practice that could not be possible with smaller numbers of events at individual organisational level. When practices improve, this in turn leads to a reduction in errors and ultimately makes systems safer for patients. 

ISO 15189 standards, as accredited by United Kingdom Accreditation Service (UKAS),¹ and the Good Practice Guidelines (GPG),² as regulated by the Blood Safety and Quality Regulations (BSQR) Statutory Instrument (SI) amendment, require laboratories to have systems in place for the identification and control of adverse events and non-conformances. This includes incident investigation and implementation of corrective and preventative actions (CAPA). GPG also states a regular review of all significant deviations or non-conformances should be conducted, including their related investigations, to verify the effectiveness of the corrective and preventive actions taken.

The 2020 Annual SHOT Report³ outlined that errors in transfusion practice account for over 80% of reports submitted each year (figure 1) and learning from these incidents allow SHOT to identify recommendations for safer transfusion practice.