2023 SHOT Report Details Transfusion-Related Events in the UK

Pulmonary complications and transfusion delays were the most common causes of transfusion-related mortality in the United Kingdom in 2023, according to the Serious Hazards of Transfusion (SHOT) annual report. Together, they accounted for 29 of 38 deaths reported to SHOT in 2023.

SHOT is the U.K.’s independent, professionally led hemovigilance program and is affiliated with the Royal College of Pathologists. Since 1996, SHOT has collected and analyzed information on adverse events and reactions in blood transfusion from almost all of the health care organizations involved in the transfusion of blood and blood components in the U.K.

The 2023 report includes 3,833 reports, reflecting an increase of 334 from the 3,499 reports analyzed in the 2022 Annual SHOT Report. As in previous years, errors accounted for the majority of reported events (3,184 of 3,833 reports, 83.1%), with a notable increase in laboratory errors (24.1%). Of these, 258 (6.7%) were “possibly preventable” and 391 (10.2%) were defined as “not preventable.” Near-miss events accounted for 37% of reported events, increasing from 1,366 in 2022 to 1,420 in 2023. The most reported near-miss events were wrong blood in tube (WBIT) errors, accounting for 69.4% of near-miss events.

There were 38 reported deaths with various grading of imputability to transfusion (certain, probable and possible), an increase of 3 from 2022. Transfusion-associated circulatory overload (TACO) accounted for 15 deaths while transfusion delays accounted for nine deaths. Other non-TACO pulmonary cases accounted for five patient deaths. There were 197 cases of major morbidity. Most cases (119, 60.4%) resulted from febrile, allergic or hypotensive transfusion reactions and TACO (20, 10.2%).

In 2023, there were two cases of major morbidity resulting from 10 ABO-incompatible transfusions. There were seven ABO-incompatible (ABOi) red cell cases. Of these, four were primarily due to administration errors and three were primarily due to administration errors resulting from a lack of pre-transfusion safety checks. There were three ABOi plasma transfusions in 2023. Of these, two were due to component selection errors in the transfusion laboratory. The third case took place in 2011 and was identified in 2023. 

Recommendations for the Future

While SHOT cites several factors as contributing to the increase in errors, the report notes that staffing challenges, in particular, are contributing to an increasing percentage of errors. “While it is encouraging to see improved hemovigilance reporting, it is evident that staff have absolutely no spare capacity and are stretched beyond breaking point with an increasing number at risk of burnout,” the report read.

In Chapter 4, the report includes recommendations to better support staff, optimize working efficiency and promote safety amidst challenges in the health care setting.

The report also includes three key recommendations to address the common themes identified as causal or contributory to adverse events that impact transfusion safety:

• Addressing patient identification errors to enhance transfusion safety Safe systems to ensure safe transfusions.
• Safe staffing to support safe transfusions.
• Effective, timely communications to ensure safe transfusions.

Each key recommendation includes actions required for hospital senior management, risk management departments and clinical and transfusion laboratory staff.

Implementing the Severity Grading Tool for Donor Adverse Events

In 2023, blood services in the U.K. agreed to implement the validated donor severity grading criteria, which was developed by the AABB Donor Hemovigilance Working Group and endorsed by ISBT, the International Haemovigilance Network and the European Blood Alliance.

Donor adverse events will be recorded according to the new grading criteria that rate severity of donor adverse events (DAEs) by Grades 1-5, with 1 through 5 being associated with mild, moderate, severe, life-threatening DAEs and death. Any event of Grade 3 or above will be reported as a serious donor complication (SDC). Once implemented by all the blood services, the reporting of SDC will replace the previous “serious adverse events of donation (SAED)” category.

SHOT anticipates that the new grading system will be fully implemented in the U.K. by 2025, resulting in more SDC being reported and recorded than in previous years. Individual U.K. blood services are implementing severity grading over different timescales. During this transition period, services may record either SDC or SAED.