The Serious Hazards of Transfusion (SHOT) Scheme was launched in November 1996 and aims to collect data on serious outcomes of transfusion of blood components.

SHOT - Serious Hazards of Transfusion

www.shotuk.org

The Serious Hazards of Transfusion (SHOT) Scheme was launched in November 1996 and aims to collect data on serious outcomes of transfusion of blood components. Through the participating bodies, the information obtained will contribute to:-

• Improving the safety of the transfusion process
• Informing policy within the Transfusion Service
• Improving standards of hospital transfusion practice
• Aiding production of clinical guidelines for the use of blood components

Participation in the scheme is voluntary and covers both NHS and private hospitals in the United Kingdom and Ireland.

The 2003 Shot Report was published on 5th July 2004. One specific recommendation made was ...

The most important contribution which could now be made to the safety of blood transfusion would be an initiative to improve the safety of bedside pretransfusion checking procedure. This will require investment in education and audit, and also in evaluation and implentation of suitable technology. The CMO's NBTC has the necessary remit to take this forward.

The following extract is taken from the 2000/2001 Annual Report and outlines the reports recommendation for the electronic monitoring of blood products within hospitals.

Electronic aids to transfusion safety should be assessed and developed at national level

Information technology has enormous potential to reduce the risk of transfusion errors. However, a coordinated approach to the development/assessment of new technologies is needed to ensure quality and 'connectability' with other key systems used in hospital, such as patient administration systems, electronic records and systems used in pharmacy and other clinical areas where positive patient ID is critical. This should be organised at a national level. The Chief Medical Officer's National Transfusion Committee in England has recently set up an IT Working Group whose first objective is to bring together the disparate agencies and projects developing clinical IT systems in the NHS. New technologies have the potential to overcome inevitable human error but need to be developed and tested in 'real-life' clinical environments to demonstrate their true value.

Electronic positive patient/blood component identification 'from vein to vein' using readily available barcode technology and wireless hand-held scanners is already undergoing field trials in the UK. In addition to improving transfusion safety, this technology has many other potential applications in the clinical setting which should increase its affordability. The same electronic ID systems could be used to reduce prescribing and drug administration errors (a considerably greater cause of morbidity and mortality than transfusion errors) and ensure correct attribution of pathology results, dietary regimens and surgical procedures. A coordinated approach is essential to avoid the nightmare scenario of multiple, incompatible, bespoke systems for transfusion, pharmacy, pathology etc in each clinical area.

• Electronic issue of blood from the laboratory without conventional serological 'crossmatching' has the potential to improve blood utilisation within a hospital and allow laboratories to meet increasing clinical workloads while maintaining patient safety. However, secure sample identification and recording of blood group/antibody screen results are absolutely essential. Ideally, electronic sample ID and a high level of automated testing with electronic data transfer should be used in laboratories using 'electronic issue'. The standards and specifications of such systems should be clearly defined in authoritative national guidelines, which are regularly reviewed to keep up-to-date with technical developments.
• Electronic control of the release of blood components from blood banks and satellite refrigerators can improve patient safety and ensure the traceability of blood units. Computer controlled systems with positive patient and product ID, preferably based on barcode reading, can protect patients from one of the most common root causes of mismatch transfusion errors identified in sequential SHOT reports - collecting the wrong unit from the refrigerator. These systems can also monitor the location and storage status of blood throughout the hospital and improve the traceability of blood as required by the new EU directive. They will be particularly valuable where a central blood bank services several geographically remote sites or a large number of satellite refrigerators. Once again, these systems should be developed and tested in routine clinical practice to ensure utility and robustness under normal working conditions.