N.B. SHOT produce several infographic summaries with each report, there is far more data than I found possible to hold in my head. Below are the few key stats I tried to remember, as they help to add emphasis to an essay in part 1 or a viva answer in part 2.

shot report 2017

Totals

3230 reports

85.5% of reports were for errors made

 

3 Key Recommendations

Training in ABO and D blood groups is essential for all clinical and laboratory staff with any responsibility for the transfusion process. This should form part of the competency assessment.

IT and Electronic blood management systems should be used and implemented to their full functionality.

A formal pre-transfusion risk assessment for TACO should be undertaken wherever possible, as TACO is the most commonly reported causes of death and major morbidity in transfusion.

 

21 Deaths in 2017

3 definitely related - 2 TACO, 1 delayed transfusion

Others probably or possibly realted to transfusion - 1 Haemolytic Transfusion Reaction, 5 Transfusion-Associated dyspnoea, 5 delayed transfusion, 5 TACO, 2 under and overtransfusion

 

Never Events

1 ABO-incompatible red cell transfusion (not fatal). 342 near misses, majority due to wrong blood in tube            (7 ABO incompatible transfusion in total inc FFP and plt)

 

Missed Irradiaton

Since 1999, when leukopletion was introduced, there have been 1397 known cases of missed irradiation of products (87 in 2017)

There have been no cases of TA-GVHD since 2001 in patients who have recived leukodepleted products     (30-35 million components transfused in this period)

(The death in 2012 was an intrauterine transfusion using maternal blood which had not been leukodepleted)

 

Other interesting snippets

See page 14 of the reports for the risks of transfusion compared to other events (hit by lightning etc)

 

SHOT Report 2016

 

Totals

3091 reports

87% of reports were errors

98.9% of near misses due to poor clinical practice (>50% pt not correctly ID’d)

 

2 Key Recommendations

1. Be like a pilot – use a bedside checklist a standard of care

2. Use a TACO checklist – TACO and pulmonary complications cause the most deaths

 

26 Deaths in 2016

3 definitely related –  1 TACO, 2 delayed transfusion.

Others probably or possibly related to transfusion, 14 TACO, 9 delays

 

Never Events

3 ABO-incompatible red cell transfusions –  2 major morbidity, 0 deaths. 264 near misses

 

 

SHOT Report 2015

 

Totals

3200 reports

80% of reports were errors --> Of which, 200 were right blood, right patient errors

700 pathological reactions

 

4 Key Messages

5 deaths associated with haemolysis

7 deaths associated with TACO

6 deaths associated with delayed transfusion

86 Acute transfusion reactions in total

 

26 Deaths in 2015

2 definitely related – 1 HTR, 1 delayed transfusion.

Others probably or possibly related to transfusion

 

Never Events

7 ABO-incompatible transfusions – 1 death and 1 renal failure. 300 near misses