ANNUAL SHOT REPORT 2017 SUMMARY

3230 TOTAL REPORTS

Possibly preventable 137 4.2%
Not preventable 333 10.3%
Errors 2760 85.5%

85.5% ERRORS Errors

85.5%

21 deaths, 14 preventable

Key SHOT messages Key recommendation 1

Do not assume, verify: At each step in the transfusion process, do not Training in ABO and D blood group
assume that no errors have been made in previous steps; verify each step, principles is essential for all laboratory
particularly patient identification and clinical staff with any responsibility for
Human factors: Failure of communication, distractions, interruptions, the transfusion process. This should form
wrong assumptions, poor handovers and overriding alerts in the laboratory part of the competency assessments
information systems are all important contributory factors
What went wrong? Thorough root cause analyses are essential and must
Key recommendation 2
identify attributable system-related and human factors so that appropriate
actions can be instituted All available information technology (IT)
systems to support transfusion practice
Is your staffing adequate? Inadequate staffing, lack of training and poor
should be considered and these systems
supervision are all likely to be associated with an increased risk of error
implemented to their full functionality.
Do not delay: Emergency transfusion saves lives. Do not let the patient bleed
Electronic blood management systems
to death or die from anaemia
should be considered in all clinical
Guidelines or rules? Guidelines must not be translated into inflexible rules settings where transfusion takes place.
which may put patients at risk. Proportionate application of knowledge and This is no longer an innovative approach
experience may lead to a different course of action in individual circumstances. to safe transfusion practice, it is the
However, the final bedside check is a rule and must be completed in full  standard that all should aim for
TACO alert: Patients who develop respiratory distress during or up to 24
hours after transfusion where transfusion is suspected to be the cause
must be reported to SHOT. The national comparative audit of TACO in 2017 Key recommendation 3
demonstrated that risk factors are being missed A formal pre-transfusion risk assessment
It is the clinician’s responsibility to know the patient’s specific transfusion for transfusion-associated circulatory
requirements overload (TACO) should be undertaken
whenever possible, as TACO is the most
ABO-incompatible red cell transfusions 2016 and 2017 commonly reported cause of transfusion-
related mortality and major morbidity
(repeat from last year)

4 ABO-incompatible
red cell transfusions ABO-incompatible transfusions:
In 2017 there was 1 ABO-incompatible red cell
transfusion (administration error),
4 of FFP and 2 of platelets
Have you instituted the full bedside
checklist?

606 ABO-incompatible
near miss events
Many more near miss events could have
resulted in ABO-incompatible red cell
transfusions.
Wrong blood in tube errors will not be
detected by the bedside check so get it right
from the start

See full SHOT Report (www.shotuk.org) for additional recommendations in the following chapters: Information Technology Incidents, Adverse Events
Related to Anti-D immunoglobulin, Immune Anti-D in Pregnancy, Transfusion-Associated Circulatory Overload, Cell Salvage and Paediatric Summary.

CONTACT DETAILS
SHOT Office, Manchester Blood Centre, Plymouth Grove, Manchester, M13 9LL
Tel: +44 (0) 161 423 4208 Enquiries: shot@nhsbt.nhs.uk www.shotuk.org
 Febrile, allergic and hypotensive
Summary data for 2017 all categories n=3230
reactions (FAHR) are the most common
NM: Near miss 1359 serious and unpredictable reactions
Anti-D: Anti-D immunoglobulin errors 426
IBCT: Incorrect blood component transfused 307
• For febrile reactions alone, give
FAHR: Febrile, allergic and hypotensive reactions 284 paracetamol
HSE: Handling and storage errors 243
RBRP: Right blood right patient 200 • For allergic reactions give an
ADU: Avoidable transfusion 101 antihistamine as first line; give
ADU: Delayed transfusion 95
adrenaline if anaphylaxis is suspected.
TACO: Transfusion-associated circulatory overload 92
HTR: Haemolytic transfusion reactions 42 The effect of steroids is delayed by
ADU: Over or undertransfusion and PCC 29 several hours, will have no immediate
TAD: Transfusion-associated dyspnoea 20
effect, and should only be used to
CS: Cell salvage 17
UCT: Unclassifiable complications of transfusion 11 prevent a late recurrence. The use of
TRALI: Transfusion-related acute lung injury 3 steroids may further immunosuppress
TTI: Transfusion-transmitted infection 1 Error
Not preventable
already immunocompromised patients
PTP: Post-transfusion purpura 0
TAGvHD: Transfusion-associated graft-vs-host disease 0 Possibly preventable and increase the risk of side effects
such as infection

Death related to transfusion (with imputability) Transfusion-related deaths 2010 to 2017 n=136
reported in 2017 n=21
60 TACO
8 TAD
Imputability
HTR 1 5 TRALI
Definite
Probable
Under and 1 1 Possible 3.7%
Preventable deaths n=14/21 (66.7%)
overtransfusion Delays 22.8% 5.9%
31 Pulmonary
complications
TAD 5 Other 16
11.7% 73
HTR 44.1%
11 53.7%
Delays 1 3 2 Febrile/ 5
allergic 8.1%
TACO 2 4 1 reactions
3.7%

0 1 2 3 4 5 6 7 8
Number of cases

Approximate risks associated with transfusion compared with other life activities: UK data (log scale)
1 in 1 in 1 in
100 million 10 million 1 million 1 in 100,000 1 in 10,000 1 in 1,000 1 in 100 1 in 10

Risk of febrile/allergic/hypotensive reaction

Risk of pulmonary
Transfusion-related deaths complications Smoking-related deaths
(by component issued)

Death from external injury

HIGHER RISK
LOWER RISK

Death from TACO (2016)

Preventable hospital deaths

Transfusion-related death
due to error Alcohol-related deaths

Death from transfusion (ISTARE) Road deaths

Air traffic accident deaths

Death from lightning strike Drowning

HCV HIV HBV

Sources of data: Many of these are found online in the UK office for national statistics. Red outline indicates SHOT data, blue outline indicates data from other sources.
ISTARE is the International Haemovigilance Network database for the surveillance of adverse reactions and events in donor and recipients. Viral transmissions denote
risk of infection, not deaths. HCV=hepatitis C virus; HIV=human immunodeficiency virus; HBV=hepatitis B virus. A full list of sources is available in supplementary
information on the SHOT website www.shotuk.org.

www.shotuk.org
@shothv1
Laboratory errors (n=409) showing at which stage in the Messages for laboratory staff
transfusion process the primary error occurred with outcome • Know your components and their compatibility
2 WCT
• Always seek the patient’s historical transfusion record
SRNM
Sample receipt and registration 7 18 18 6 24
HSE • Do not override warning alerts
1 RBRP
Testing 10 63 8 9 19 Avoidable • Follow the correct procedures
Delayed
1
Anti-D Ig Laboratory errors and near miss incidents n=740
Component selection 24 21 8

1
showing at which stage the primary error occurred
173
Component labelling 72 58 12 6
Laboratory errors
149
Laboratory near miss
Collection 3

2 110
Miscellaneous 3 8 5

0 20 40 60 80 100 120 140 160 75

53 53 54 52

The 9 steps in the transfusion process 18

3
1 REQUEST
Sample receipt Testing Component Component Collection Miscellaneous
and registration selection labelling
2 SAMPLE TAKING

3 SAMPLE RECEIPT
Critical points where
positive patient
identification is
4 TESTING Critical points Points in the process where the first mistake occurred
in the laboratory
essential 5 COMPONENT SELECTION
(clinical and laboratory) leading to wrong component
6 COMPONENT LABELLING transfused (WCT) or specific requirements not being
7 COMPONENT COLLECTION met (SRNM) n=307
8 PRESCRIPTION
Request 3 109
9 ADMINISTRATION
Sample taking 2

Sample receipt 7 18

Testing 10 63

Overview of reports where an incorrect blood component Component selection 24 21

was transfused in 2017 n=307 Component labelling 1

Collection 26

Prescription 2
Incorrect blood component transfused n=307 (100%)
Administration 5 1 WCT
SRNM
Miscellaneous 5 10
Clinical 149 (48.5%)
0 20 40 60 80 100 120
Laboratory 158 (51.5%)
WCT=wrong component transfused; SRNM=specific requirements not met

Near miss wrong component transfusions are mostly due

Wrong component Specific requirements to wrong blood in tube (WBIT) incidents
transfused n=82 not met n=225

35 (42.7%) 114 (50.7%)

2 59
47 (57.3%) 111 (49.3%) 18
31

Paediatric reports where incorrect blood components

were transfused n=41 (by age)
WBIT
IBCT-WCT Totals 11 3 4 18
87.8%
Laboratory 4 2 3 9
Category of IBCT report

Clinical 7 1 1 9

IBCT-SRNM Totals 4 5 10 4 23 789

Irradiated 1 3 1 5 Request errors

MB- or ≤28 days Laboratory errors

1 2 3
SD-plasma >28 days to <1 year Collection
Others 3 4 7 1 15 1 to <16 years Administration
16 to <18 years Wrong blood in tube (WBIT)
Serious Adverse Events following Blood Donation reported
to the UK Blood Services in 2017
In 2017 the UK Blood Services collected approximately 1.9
million donations. Fifty serious adverse events of donation
(SAED) have been reported last year (1 in 38,273 donations).
Serious adverse events are very rare but do occur and can have a
significant impact on donor health and donor retention

Breakdown of Serious Adverse Events in 2017

SAED Categories
ACS, 2 Death , 1 18/50 SAED were as a

36%
direct result of a
delayed vasovagal
Hospital reaction
Arm admission,
problems 13
>12/12…
17/50 SAED were
Fracture,

34%
15 related to persistent
RTC, 1 arm problems more
Other, 1 than one year post
ACS=acute coronary syndrome
RTC=road traffic collision donation

Female donors accounted for nearly In general 9/10 donors who suffer an SAED are
2/3 of SAED reported withdrawn from future donations

Key Messages
No reports of anaphylaxis,
haemolysis or air
embolism due to
component donation Vasovagal events resulting
reported in 2017 Donors need a clear in donor hospitalisation or
understanding of what, injury and nerve injuries
when and how to report post venepuncture continue
All 15 fractures were adverse events to be the commonly
related to vasovagal
reactions, 2 immediate reported SAED
and 13 delayed reactions

There was one report of a

donor death <7 days of Whole blood and
donation and two reports component donation is safe
of acute coronary but complications do
syndrome <24 hours of sometimes occur
donation

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