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SHOT Publications – Abstracts

BBTS 2016

Bolton-Maggs PHB, Grey S,  Poles D, Ball J, Lucero H. Time to refine transfusion-associated circulatory overload (TACO) Transfus Med 2016; 26 (Suppl 2) PO 69: 50

New H, Poles D, Clarke P,, Bolton-Maggs PHB. Errors in and complications of paediatric blood transfusion: SHOT 2015. Transfus Med 2016; 26 (Suppl 2) PO 73: 51

Bolton-Maggs P. Transplantation and transfusion slip-ups. Transfus Med 2016; 26 (Suppl 2) S101: 5

Bolton-Maggs PHB, Ball J, Poles D, Keidan J. Immune anti-D detected for the first time in pregnancy: preliminary results of cases reported to SHOT from 2012-2015: optimal care fails to protect. Transfus Med 2016; 26 (Suppl 2) S102: 5

Mistry H, Ball J, Baker P, Poles D, Bolton-Maggs PHB. Multiple laboratory errors resulting in transfusion of incorrect blood components. Transfus Med 2016; 26 (Suppl 2) S1O3: 5

Milkins C, Mistry H, Poles D, Bolton-Maggs PHB. Delayed haemolytic transfusion reactions (DHTR) and simple alloimmunisation are associated with different antibody specificities. Transfus Med 2016; 26 (Suppl 2) PO 02: 25

Bolton-Maggs PHB, Ball J, Grey S, Latham T, Poles D. The changing pattern of pulmonary complications reported to SHOT. Transfus Med 2016; 26 (Suppl 2) PO 12: 28

Narayan S, Barnes S, Field S, Wells A, Maguire K, Bolton-Maggs PHB. A SHOT at donor Haemovigilance. Transfus Med 2016; 26 (Suppl 2) PO 43: 39

Milkins C, Ball J, Poles D, Bark J, Bolton-Maggs PHB. Risk and impact of haemolytic transfusion reactions due to passive ABO antibodies as evidenced by SHOT data. Transfus Med 2016; 26 (Suppl 2) PO 52: 43

Watt A, Ball J, Poles D, Bolton-Maggs PHB. ABO-incompatible transfusions – nearly 300 prevented by staff vigilance in 2015. Transfus Med 2016; 26 (Suppl 2) PO 67: 49

Birchall J, Cowan K. The Serious Hazards of Transfusion reporting scheme has a valuable role in identifying changes in transfusion reaction patterns associated with new components. Transfus Med 2016; 26 (Suppl 2) PO 64: 47

ISBT 2016

Allard S, Bolton-Maggs PHB, Poles D on behalf of the SHOT steering group. Transfusion adverse events in patients with haemoglobinopathy – reports to the Serious Hazards of Transfusion UK Haemovigilance scheme, 2010-2015. Vox Sang 2016; 111 (Suppl 1) Oral 5C-S42-03, 77

Africa Society for Blood Transfusion 2016

Bolton-Maggs PHB Kigali, May 2016  ‘Haemovigilance and the SHOT initiative’

Italian Society of Transfusion (SIMTI) 2016

Bolton-Maggs PHB. Bologna, May 2016 ‘SHOT and SABRE: towards a single system’. Blood Transfusion 2016; 14 Suppl 3: s166(RE43)

BSH 2016

Allard S, Bolton-Maggs PHB, Poles D. Transfusion adverse events in paitents with haemoglobinopathy – reports to the serious Hazards of Transfusion UK Haemovigilance scheme 2010-2014. Br J Haematol 2016; 173 (Suppl 1) Oral 31.

Bark J, Grey S, Watt A, Rook R, Bolton-Maggs PHB. Laboratory surveys from UK Transfusion Laboratory Collaborative (UKTLC) confirm cause for concern. Br J Haematol 2016; 173 (Suppl 1) Oral 32.

Ball J, Mistry H, Gallagher C, Poles D, Watt A, Bolton-Maggs PHB. Serious Hazards of Transfusion (SHOT) scheme analysis of cumulative errors in incorrect blood component transfused haemovigilance reports 2013-2014. Br J Haematol 2016; 173 (Suppl 1) Poster 388.

IHN 2016

Bark J, Grey S, Watt A, Rook R, Bolton-Maggs PHB. Laboratory surveys from UK Transfusion Laboratory Collaborative (UKTLC) confirm cause for concern. Blood Transfusion 2016; 14 Suppl 1 – 17th IHN Seminar

Bolton-Maggs PHB. Human factors and transfusion errors (invited talk). Blood Transfusion 2016; 14 Suppl 1 – 17th IHN Seminar

BBTS 2013

Lessons from the transfusion-related deaths reported to SHOT in 2012. Paula Bolton-Maggs, Debbi Poles, Hannah Cohen, Catherine Chapman, Mark Kilby and Helen New. (Oral presentation)

Potentially unsafe transfusion practice: two lessons from a SHOT case report. Julie Ball and Paula Bolton-Maggs

No improvement in rate of errors in pretransfusion testing-comparison between 2-year periods a decade apart. Hema Mistry, Tony Davies, Alison Watt, Deborah Asher, Christine Gallagher, Debbi Poles and Paula Bolton-Maggs

Incorrect transfusions in transplant patients as a result of poor communication. Alison Watt, Debbi Poles, Paula Bolton-Maggs

What can we learn from specialty-related incidents reported to SHOT 2010-2012? Paula Bolton-Maggs, Debbi Poles, Hannah Cohen.

ISBT 2013

Helen New et al. Fatal TAGvHD following emergency IUT: case report and survey of UK practice. (Poster)

 Debbi Poles et al. Review of 3 years of reporting to SHOT’s web-based haemovigilance data capture system. (Poster)

 Hema Mistry et al. Human errors associated with manual techniques with or without automation in ABO/RhD grouping are associated with potentially lethal outcomes (Oral)

 Hazel Tinegate et al. Management of  Immunoglobulin A deficiency: lessons from haemovigilance  (Oral)

BSH 2013

Laboratory-related transfusion errors – information technology is not a foolproof solution – oral presentation by Chris Gallagher

Adverse events related  to blood transfusion: haemoglobinopathy patients are particularly at risk – oral presentation by Paula Bolton-Maggs

Red cell transfusions: delays in setting up and extended transfusion times have not been associated with any adverse outcomes – analysis of 30 months’ data reported to SHOT – oral presentation by Paula Bolton-Maggs and Alexandra Gray

Delays in the transfusion of blood reported to the UK confidential haemovigilance scheme (Serious Hazards of Transfusion) Paula Bolton-Maggs and Julie Ball – poster presentation

Adverse incidents related to transfusion – haematology patients are at higher risk for missed specific requirements – poster presentation by Paula Bolton-Maggs

IHN 2013

Laboratory-related transfusion errors – information technology is not a foolproof solution – oral presentation by Chris Gallagher

AABB 2010

Developing a new web based haemovigilance data capture system for SHOT. D Mold, H Jones, H Cohen, C Taylor. Transfusion

BBTS 2010

Transfusion Associated Circulatory Overload: Reporting to SHOT.  D Mold, H Cohen, H Jones and C Taylor. Transfusion Medicine 2010; 20, (Suppl 1) 14.  

ISBT 2010

New Trends in Blood Component Administration Errors Reported to SHOT.  Mold DR, Norfolk D, Jones H, Taylor C, Cohen H. Vox Sanguinis (2010) 99 (Suppl. 1), 1–516

BSH 2010

Developing a new web based haemovigilance data capture system for SHOT. DR Mold, H Jones, CPF Taylor, H Cohen. British Journal of Haematology, 149, (Suppl. 1), 65.

IHN 2010

Developing a  New Web Based Haemovigilance Data Capture System for SHOT. (Seminar Presentation). Mold D Jones H, Taylor C, Cohen H. Blood Transfusion, 2010; 8 Suppl. 1, s44.

BSH 2009

Serious Hazards of Transfusion (SHOT) reports relating to anti-D immunoglobulin. T Davies, C Taylor, H Jones, H Cohen. British Journal of Haematology, 145 (S1): 77-78.

Serious Hazards of Transfusion (SHOT) near miss reporting. T Davies, C Taylor, H Jones, H Cohen. British Journal of Haematology, 145 (suppl. S1) 49-50.

BBTS 2009

Participation in SHOT Reporting 2006-2008. D Mold, H Jones, C Taylor, H Cohen. Transfusion Medicine, 19 (Issue s1)

Serious Hazards of Transfusion (SHOT) reports relating to anti-D immunoglobulin. T Davies, C Taylor, H Jones, H Cohen. Transfusion Medicine, 19 (Issue s1)

AABB 2009

Benchmarking Participation in Haemovigilance in the United Kingdom. D Mold, H Jones, C Taylor, H Cohen. Transfusion, 49 (Issue S3)

Serious Hazards of Transfusion (SHOT) reports relating to anti-D immunoglobulin. T Davies, C Taylor, H Jones, H Cohen. Transfusion, 49 (Issue S3)

NATA 2009

Pilot of an adverse event reporting system for cell salvage incidents.  Joan Jones1, Catherine Howell2, Hilary Jones3 & Clare Taylor3. 1 Welsh Blood Service, Cardiff, Wales UK. 2NHS Blood and Transplant, England, UK, 3SHOT, UK

Jones J, Howell C, Jones H, Taylor C. P. F. (2009) Pilot of an adverse event reporting system for cell salvage incidents.

EHN 2009

Seminar Presentation. Haemovigilance – The role of junior doctors.  Dr. Clare P F Taylor, Medical Director SHOT, UK. 11th European Haemovigilance Seminar 25th – 27th February 2009 

Pilot of an adverse event reporting system for cell salvage incidents.  Joan Jones1, Catherine Howell2, Hilary Jones3 & Clare Taylor3. 1 Welsh Blood Service, Cardiff, Wales UK. 2NHS Blood and Transplant, England, UK, 3SHOT, UK. 11th European Haemovigilance Seminar 25th – 27th February 2009

Scientific Symposium of the Research Foundation of the Blood Services of the German Red Cross 2009

Chapman CE  Oral Presentation at Tenth Scientific Symposium of the Research Foundation of the Blood Services of the German Red Cross.  Safety of Blood Products.  Dresden, 6th November 2009 SHOT experience in collecting TRALI cases and in the prevention of TRALI.

NATA 2008

Chapman CE and Williamson LM on behalf of SHOT Steering Group.  Effect of leukodepletion on the incidence of post-transfusion purpura and transfusion-associated graft-versus-host disease.  Transfusion Alternatives in Transfusion Medicine June 2008 10 (suppl 1) p1

ISBT 2006

Chapman CE, Williamson LM, Cohen H, Stainsby D, Jones H. The impact of using male donor plasma on haemovigilance reports of transfusion related acute lung injury (TRALI) in the UK.  Vox Sanguinis July 2006 91 (suppl 3) p501

Williamson M, Stainsby D, Jones H, Love E, Chapman C, Casbard A, Cohen H. Haemovigilance reports of post-transfusion purpura and transfusion-associated Graft versus host disease before and after implementation of universal leukodepletion in the UK. Vox Sanguinis July 2006 91 (suppl 3) p15

EHN 2006

Taylor C, Stainsby D, Cohen H, Saunders R. (2006) SABRE – UK haemovigilance gets sharper. EHN, Amsterdam.

ISBT 2005

D Stainsby, SM Knowles, C Milkins, H Jones & H Cohen. Can haemolytic transfusion reactions be avoided by better laboratory practice? 2005 Vox Sanguinis , 89, S1

ISBT 2004

Williamson LM, Stainsby D, Beatty C, Chapman C, Jones H, Love E, Cohen H. on behalf of the Serious Hazards of Transfusion Steering Group. Six years TRALI reporting in the UK leading to male FFP. ISBT Edinburgh, July 2004. Vox Sanguinis 2004:87(S3):4.

Davison KL, Dow BC and Barbara JA. Transfusion Transmitted Infections in the UK: Microbial Highlights of SHOT. July 2004. Vox Sanguinis 2004:87 (S3):

Gibson B, Stainsby D, Todd AMM, Jones H, Cohen H. Serious Hazards of Transfusion in Children. Vox Sang 2004;87(s3): 91

BSH 2004

Stainsby D, Cohen H, Jones H, Beatty C, Williamson L. on behalf of the SHOT Steering Group. Transfusion Related Acute Lung Injury: A major cause of transfusion associated mortality and morbidity. BSH 44th Annual Scientific Meeting, Cardiff, April 2004. Br J Haem 2004;125(S1):34.

ISBT 2003

Stainsby D. Haemovigilance in the UK – how has the SHOT scheme contributed to patient safety? Blood Banking and Transfusion Medicine 2003; 1.1 (1):S29

BBTS 2003

Stainsby D, Jones H, Cohen H. Now we are six – an update of the Serious Hazards of Transfusion Scheme. Transfusion Medicine 2003;13(1): 5

Congrès de la SFTS 2001

Teesdale, P. Regan, F. Taylor, C. (2001) Right blood to right patient – a new video to educate healthcare workers. Transfusion clinique et biologique, 2001; 8 (S1):27.

EHA 2001

Taylor C P F. Regan F, Teesdale P. (2002) Wrong blood to wrong patient – a new training video to prevent this occurring. The Hematology Journal, 3 (S1): 415

AABB 2000

Love EM, Williamson LM, Cohen H, Jones H. on behalf of the SHOT Steering Group, SHOT Office, Manchester Blood Centre, UK haemovigilance in the UK: what have the first three years of the Serious Hazards of Transfusion scheme (SHOT) achieved? Transfusion 2000, 40, 10S: 44S (AABB Washington)

EHA 2000

Love EM, Williamson LM, Cohen H. 2000 The contribution of “wrong blood” episodes to transfusion morbidity / mortality. Abstract 456, The Haematology Journal, June 2000;1(10):119

BBTS 2000

Love EM, Williamson LM, Cohen H, Jones H. on behalf of the SHOT Steering Group. The Serious Hazards of Transfusion (SHOT) reporting scheme: outcome of the first three years of reporting, (XVIII Annual Scientific Meeting of the British Blood Transfusion Society 2000), Transfusion Medicine 2000;10(1), 012

ISBT 2000

Love EM, Williamson LM, Cohen H. on behalf of the SHOT Steering Group. The Serious Hazards of Transfusion (SHOT) scheme: lessons from the first three years, Vox Sanguinis 2000:78/S1/00,0147

IIIEME Congres National de Securité Transfusionnelle et d’Hemovigilance 1999

Cohen H, Love E, Williamson L. Haemovigilance in the UK : serious hazards of transfusion (SHOT). IIIEME Congres National de Securité Transfusionnelle et d’Hemovigilance. Conference Proceedings 44

Crises in Haematology meeting June, 1999

Cohen H, Love E, Williamson L. Serious Hazards of Transfusion (SHOT),. The Bulletin of the Royal College of Pathologists; Abstracts Section, 1999;108:111

BSH 1999

Cohen H, Love E, Lowe, S, Williamson L. on behalf of the SHOT Steering Group. Serious Hazards of Transfusion (SHOT) Scheme: The Second Annual Report 1997-98 Br J Haematol 1999;105(1):30;13

Cohen H, Love E, Williamson L. Serious hazards of transfusion (SHOT) and blood safety. Clin Lab Haematol 1999;21:4-5

ISBT 1998

Williamson LM, Love E, Lowe S. et al for the SHOT Steering Group. UK Serious Hazards of Transfusion (SHOT) initiative – results from the first year of reporting. Vox Sanguinis, 74/S1/98