serious hazards of transfusion (shot) reports


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.


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shot report 2022

Totals

2.2 million blood components issued in the UK in 2022

3499 reports analysed by SHOT, 83.1% were for errors made

Risk associated with transfusion in UK

  • Serious harm: 1 in 15,450 units transfused (6.47 per 100,000)

  • Death: 1 in 63,537 units transfused (1.57 per 100,000)

4 Main Recommendations

  1. Appropriate management of anaemia and making safe transfusion decisions

  2. Safe systems to ensure safe transfusions

  3. Effective implementation of appropriate interventions following incident investigation

  4. Learning from excellence and day-to-day events

35 Deaths in 2022

3 deaths definitely attributable to transfusion delay - 1 each of transfusion delay, TACO and Pulmonary Non-TACO

32 probably or possibly related to transfusion - 12 delays, 7 TACO, 6 Pulmonary Non-TACO, 2 IBCT-WCT, 2 PCC, 1 HTR, 1 FAHR, 1 UCT

Never Events in 2022

6 ABO-incompatible transfusions (2 preventable deaths).

In addition there were 890 ‘wrong blood in tube’ (WBIT) errors, 320 of which that could have resulted in ABO-incompatible transfusion.

shot report 2020

N.B. Covid-19 year. Big drop in blood product issuing in April. Reporting rates as a % of products issued actually stayed largely the same. Shows the strength of the SHOT scheme and those reporting into it.

Totals

2 million blood components issued in the UK in 2020

3214 complete reports analysed by SHOT, 81.6% were for errors made

—> Risk associated with transfusion in UK - Serious harm: 1 in 15,142, and Death: 1 in 53,193

Viral TTI: Estimates based on 1996-2020, that a donation made in the window period is not detected by screening - Hep B 0.87, Hep C <0.01, HIV 0.04 (No. per million donations)

Key Messages

TACO and Transfusion Delays remain the most common causes of transfusion-related death.

Ensure transfusion teams are well resourced

Address knowledge gaps, cognitive biases and holistic training

Foster a patient safety culture

Standard operating procedures need to be simple, clear and easy to follow

Learn from near misses

Learn from the pandemic


39 Deaths in 2020 (steep increase from 2019)

1 death definitely attributable to transfusion delay

38 probably or possibly related to transfusion - 18 TACO, 11 delays, 4 TAD, 3 Uncommon complications, 1 under-transfusion, 1 TRALI


Never Events in 2020

9 ABO-incompatible transfusions (all not fatal. 7 RBC, 1 FFP, 1 Covid-19 convalescent plasma). 5 of these cases took places out of hours, despite 3 of them being classed as elective transfusions. In addition there were 673 ‘near miss - wrong blood in tube’ errors that could have resulted in ABO-incompatible transfusion.

shot report 2019


Totals

2.3 million blood components issued in the UK in 2019

4248 total reports submitted to SHOT, 84% were for errors made

—> Risk associated with transfusion in UK - Serious harm: 1 in 17,884, and Death: 1 in 135,705


Key Recommendation

Accurate patient identification is fundamental to patient safety

Clinical and laboratory staff should be trained in fundamentals of transfusion, human factors, cognitive bias, investigating incidents and patient safety principles.

All healthcare organisations should incorporate the principles of Safety-I and Safety-II approaches to improve patient care and safety.

Healthcare management must recognise that safety and outcomes are multifaceted, a linear view of safety does not fully acknowledge the interdependencies of resources including their leadership, adequate staffing and knowledge.


17 Deaths in 2019

1 from transfusion-transmitted infection (Hep E)

16 probably or possibly related to transfusion - 9 TACO, 2 delays, 2 Uncommon complications, 1 TAD, 1 under-transfusion, 1 related to use of PCC,


Never Events

6 ABO-incompatible transfusions (all not fatal. 4 RBC, 2 FFP). In addition there were 308 ‘near miss - wrong blood in tube’ errors that could have resulted in ABO-incompatible transfusion.


SHOT report 2018

Totals

3326 reports

87.3% of reports were for errors made


3 Key Recommendations

All NHS organisations must move away from a blame culture towards a just and learning culture

All clinical and laboratory staff should be encourage to become familiar with human factors and ergonomic concepts

All transfusion decisions must be made after carefully assessing the risks and benefits of transfusion therapy. Collaboration and co-ordination among staff is vital.


20 Deaths in 2018

0 were felt to be definitely related to transfusion

Probably or possibly related - 8 delayed transfusion, 1 overtransfusion, 2 HTR, 3 TACO, 2 TAD, 1 TRALI, 1 TTI


Never Events

4 ABO-incompatible red cell transfusions (not fatal). In addition there were 290 ‘near miss - wrong blood in tube’ errors that could have resulted in ABO-incompatible transfusion.


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 cause of death and major morbidity in transfusion.

 

21 Deaths in 2017

3 definitely related - 2 TACO, 1 delayed transfusion

Others probably or possibly related 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 report 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