SHOT: annual report results

2010 has been the first year in which there has been no confirmed cases of transfusion-transmitted infection (TTI), according to the annual Serious Hazards of Transfusion (SHOT) report. The report is the 14th annual report of data collected and recommendations made by the SHOT UK Haemovigilance Scheme. Reports were submitted by 94.7% of NHS hospitals or Trusts. 91.4% of these organisations reported incidents in three broad categories – adverse events, near misses and physiological reactions. In total, 1464 cases were analysed (in addition to 863 instances of near miss and 137 right blood right patient incidents), which represents a 14.5% increase from 2009. Another interesting figure highlighted by the report is the fact that there has been a 29% reduction, overall, in the number of incorrect blood component transfused (IBCT) reports: 57% less in the clinical area and 28% less in the laboratory, indicating that efforts to train and competency assess clinical staff in transfusion, such as the National Patient Safety Agency (NPSA) Safer Practice Notice (SPN) 14, are having an effect in the clinical area.

Deaths

 The report has identified that, to a varying extent, transfusion contributed to 13 deaths in the reporting period. There were also 101 reports of major morbidity, with acute transfusion reactions (ATR) being the single highest cause, resulting in a serious outcome for 7.8% of reported cases. Three deaths were definitely due to transfusion. There was one case of sudden unexpected death during a red cell transfusion. Although there were no diagnostic changes on post mortem examination, the death was attributed to an anaphylactic reaction on the basis of mast cell tryptase levels on a post-mortem blood specimen. The second death was due to transfusion-associated circulatory overload (TACO), again confirmed on a coroner’s post-mortem, and the third death occurred in a child with sickle cell disease who suffered from hyperhaemolysis exacerbated by further transfusion. TACO was the most common reaction implicated in death, contributing to the demise of six further patients – three where death was assessed as highly likely or probably due to the transfusion and three where the possibility that TACO had contributed to death could not be excluded. One of the deaths from TACO was due to over-transfusion