6 Years of shot reporting--its influence on UK blood safety.
Recognition of the importance of systematic surveillance of adverse effects of transfusion has led to the development of haemovigilance schemes [Faber JC. Haemovigilance around the world. Vox Sang 2002;83(suppl.1):71], of which the Serious Hazards of Transfusion (SHOT) scheme, launched in 1996, was one of the first. Over 90% of UK hospitals now participate in the scheme; in 6 years of reporting, SHOT analysed 1630 events of which 64% were errors in the transfusion process, leading to 193 instances of ABO incompatible transfusion. Transfusion related acute lung injury, bacterial contamination of platelets and transfusion-associated graft-versus-host disease were also identified as important preventable causes of mortality and morbidity. Data from SHOT has provided evidence to support the development of blood safety strategies in the UK.
Stainsby
Dorothy
D
Serious Hazards of Transfusion (SHOT) Steering Group and Standing Working Group, SHOT Office, Manchester Blood Centre, Manchester M13 9LL, UK. dorothy.stainsby@nbs.nhs.uk
Williamson
Lorna
L
Jones
Hilary
H
Cohen
Hannah
H
D001771:Blood Banks / Q000458:organization & administration / Q000592:standards*; D003625:Data Collection; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D012308:Risk Management / Q000458:organization & administration*; D012449:Safety; D065227:Transfusion Reaction; D006113:United Kingdom