| GENERAL RECOMMENDATIONS |
| Active participation in SHOT must continue | Trust Chief Executive Officer’s (CEOs) through Hospital Transfusion Committees (HTCs) and risk management structures, consultant haematologists, hospital staff involved in the blood transfusion process |
| An open learning and improvement culture must continue to be developed in which SHOT reporting is a key element | Trust CEOs through risk management structures, staff involved in the blood transfusion process |
| Hospital transfusion teams (HTTs) must be established and supported | Trust CEOs through HTCs |
| Hospital transfusion laboratory staffing must be sufficient for safe transfusion practice | Trust CEOs |
| Education and training are of key importance for safe and effective blood transfusion practice. Education in blood transfusion must be included in the curriculum for all clinical staff involved in prescribing and administering blood. Adequate resource is needed in Trusts to ensure that all staff involved in the transfusion chain in hospitals must receive appropriate training, which must be documented. Effectiveness of training should be assessed with assessment based on competency | Trust CEOs |
| Mechanisms must be put in place for appropriate and timely communication of information regarding special transfusion requirements | Trust CEOs |
| Appropriate use of blood components must be strenuously promoted and evaluated. This must include monitoring for serious adverse effects of alternatives to transfusion | Trust CEOs through HTCs |
| INCORRECT BLOOD COMPONENT TRANSFUSED |
| The EU Directive requires that hospital transfusion laboratories implement a quality system. Elements of this include ensuring adequate staffing levels, systematic and documented training, validation of methods and change control. This presents an opportunity to drive improvements in practice and must be fully supported, resourced and monitored. | Trust CEOs |
| NEAR MISS |
| All staff involved in the pre-transfusion sampling, testing and issue of blood must be deemed competent having undergone appropriate training, which must be documented. | Trust CEOs through risk management structures |