SHOT: transfusion hazards highlighted

The 12th SHOT Annual Report was published at the end of June 2009 to coincide with the submission of haemovigilance data to the EU Commission by the competent authority, the Medicines and Healthcare products Regulatory Agency (MHRA). Over 12 years of reporting, the trends observed by SHOT have borne the hallmarks of an effective vigilance system. The number of events reported has risen, while the frequency of the most serious events, and the mortality directly related to transfusion, has fallen. As the culture of reporting has developed, there has been an increased understanding of how an adverse event system exerts its influence (i.e. by the observation and reporting of trends and patterns, followed by changes of practice to reduce the risks of recurrence, rather than by the creation of a “blame culture”). SHOT demonstrates the utility of an effective haemovigilance system in increasing patient safety through the promotion of a culture of learning and improvement, with an emphasis on safety and quality.

Organisations that require evidence of reporting to SHOT

In the past, reporting to SHOT has been voluntary. However, in recent years a number of quality, inspection and accreditation organisations and Government bodies within the United Kingdom have made reporting to SHOT a requirement. SHOT has identified all of these organisations and their specific requirements and they are listed in the full report.