Serious Hazards of Transfusion (SHOT) is the

United Kingdom The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and North ...

's haemovigilance scheme. It collects and analyses anonymized information on

adverse events An adverse event (AE) is any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An adverse event can ther ...

and

blood transfusion Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mo ...

reactions. When SHOT has identified risks related to transfusion, it produces recommendations within its annual reports to improve

patient safety Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of a ...

. These reports are freely available on its website. SHOT, together with the Medicines and Healthcare products Regulatory Agency (MHRA), works to support haemovigilance reporting in the UK.

Results

SHOT's statistical data has been used to decrease

bacterial infections Pathogenic bacteria are bacteria that can cause disease. This article focuses on the bacteria that are pathogenic to humans. Most species of bacteria are harmless and are often beneficial but others can cause infectious diseases. The number of t ...

through better skin cleansing procedures and the incidence of life-threatening transfusion-related acute lung injury (TRALI) in the UK, by discouraging the use of

fresh frozen plasma Fresh frozen plasma (FFP) is a blood product made from the liquid portion of whole blood. It is used to treat conditions in which there are low blood clotting factors (INR > 1.5) or low levels of other blood proteins. It may also be used as the re ...

from female donors. The cause of TRALI is not fully understood, and may have more than one mechanism, but most cases are associated with transfusion of plasma or other blood products that contain some

antibodies An antibody (Ab), also known as an immunoglobulin (Ig), is a large, Y-shaped protein used by the immune system to identify and neutralize foreign objects such as pathogenic bacteria and viruses. The antibody recognizes a unique molecule of the ...

that the donor developed during

pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ca ...

. Not using plasma donation from female donors for transfusions eliminates the risk of exposing the recipient to pregnancy-related antibodies, and therefore reduces the risk of TRALI. The collected information has also provided evidence to support the pre-existing practice of leukodepletion (depleting the number of

leukocytes White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from mult ...

, or white blood cells, from the product) to reduce the risk of transfusion-associated

graft-versus-host disease Graft-versus-host disease (GvHD) is a syndrome, characterized by inflammation in different organs. GvHD is commonly associated with bone marrow transplants and stem cell transplants. White blood cells of the donor's immune system which remain wit ...

and

post-transfusion purpura Post-transfusion purpura (PTP) is a delayed adverse reaction to a blood transfusion or platelet transfusion that occurs when the body has produced alloantibodies to the allogeneic transfused platelets' antigens. These alloantibodies destroy the pat ...

in immunocompromised patients. SHOT's data has also focused attention on

human error Human error refers to something having been done that was " not intended by the actor; not desired by a set of rules or an external observer; or that led the task or system outside its acceptable limits".Senders, J.W. and Moray, N.P. (1991) Human ...

s, with the result that staff training and procedures have been improved. For example, SHOT's data demonstrated that increasing the use of wristbands for patient identification and portable, bedside

barcode reader A barcode reader is an optical scanner that can read printed barcodes, decode the data contained in the barcode to a computer. Like a flatbed scanner, it consists of a light source, a lens and a light sensor for translating optical impulses into e ...

s reduced the risk of an error caused by

human factors Human factors and ergonomics (commonly referred to as human factors) is the application of psychological and physiological principles to the engineering and design of products, processes, and systems. Four primary goals of human factors learnin ...

History

SHOT was established in 1996. During the first ten years, it collected more than 2,000 confidential reports about transfusion safety problems or near misses. During the first two years of voluntary reports, about half of these errors involved giving the wrong type of blood or blood component to a patient. This happens, for example, if hospital staff accidentally take the wrong item out of the blood bank refrigerator. Less than 1% of errors resulted in an infection. By 2012, almost all NHS hospitals, trusts, and health boards had registered with SHOT and were submitting reports. Participation is now mandatory. The "Better Blood Transfusion" strategy by the UK's Department of Health was based on evidence collected by SHOT.

References

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External links

Official website
Transfusion medicine Transfusion reactions 1996 establishments in the United Kingdom Medical and health organisations based in the United Kingdom