title: Serious hazards of transfusion: a decade of hemovigilance in the UK.
abstract: The Serious Hazards of Transfusion (SHOT) scheme is a UK-wide, independent, professionally led hemovigilance system focused on learning from adverse events. SHOT was established in 1996 as a confidential reporting system for significant transfusion-related events, building an evidence base to support blood safety policy decisions, clinical guidelines, clinician education, and improvements in transfusion practice. Recommendations are formulated by an independent steering group drawn from medical royal colleges and professional bodies. Ten years after its inception, SHOT has analyzed 2630 transfusion safety events, published 8 annual reports with recommendations, and presented data nationally and internationally. These recommendations have underpinned key initiatives, in particular the UK Department of Health "Better Blood Transfusion" strategy. SHOT has encouraged open reporting of adverse events and "near-misses" in a supportive, learning culture, vigilance in hospital transfusion practice, and evaluation of information technology to support this process. The importance of education and training has been emphasized. Detailed analysis of events has identified weaknesses in the transfusion chain. A collaborative initiative between SHOT, the Chief Medical Officer for England's National Blood Transfusion Committee, and the National Patient Safety Agency aims to reduce ABO-incompatible transfusions by improving bedside practice. Cumulative SHOT data have documented the decline in transfusion-related graft vs host disease after implementation of leucodepletion and have highlighted transfusion-related acute lung injury and bacterial contamination of platelets as important causes of death and morbidity. The UK blood services have developed strategies to reduce these risks. Future SHOT data will evaluate the success of these and other blood safety improvements.
authors.affiliation: dorothy.stainsby@nbs.nhs.uk
authors.forename: Dorothy
authors.initials: D
authors.lastname: Stainsby
authors.forename: Hilary
authors.initials: H
authors.lastname: Jones
authors.forename: Deborah
authors.initials: D
authors.lastname: Asher
authors.forename: Claire
authors.initials: C
authors.lastname: Atterbury
authors.forename: Aysha
authors.initials: A
authors.lastname: Boncinelli
authors.forename: Lisa
authors.initials: L
authors.lastname: Brant
authors.forename: Catherine E
authors.initials: CE
authors.lastname: Chapman
authors.forename: Katy
authors.initials: K
authors.lastname: Davison
authors.forename: Rebecca
authors.initials: R
authors.lastname: Gerrard
authors.forename: Alexandra
authors.initials: A
authors.lastname: Gray
authors.forename: Susan
authors.initials: S
authors.lastname: Knowles
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Love
authors.forename: Clare
authors.initials: C
authors.lastname: Milkins
authors.forename: D Brian L
authors.initials: DB
authors.lastname: McClelland
authors.forename: Derek R
authors.initials: DR
authors.lastname: Norfolk
authors.forename: Kate
authors.initials: K
authors.lastname: Soldan
authors.forename: Clare
authors.initials: C
authors.lastname: Taylor
authors.forename: John
authors.initials: J
authors.lastname: Revill
authors.forename: Lorna M
authors.initials: LM
authors.lastname: Williamson
authors.forename: Hannah
authors.initials: H
authors.lastname: Cohen
mesh_terms: D001803:Blood Transfusion / Q000401:mortality / Q000592:standards; D003625:Data Collection; D006801:Humans; D011358:Product Surveillance, Postmarketing / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D065227:Transfusion Reaction; D006113:United Kingdom