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Presentations from SHOT Symposia

SHOT Symposium 2021


SHOT Virtual Symposium Programme 2021


Click here for the full programme of the SHOT Symposium 2021

2020 Annual SHOT Report Highlights (pdf)

Live illustrations were carried out by Jenny Leonard (see images below).

SHOT Webinar 2020

The 2019 Annual SHOT Report was published on Tuesday 7th July 2020, and launched by way of a webinar rather than the usual face to face Symposium.

The webinar comprises a 40 minute presentation by Dr Shruthi Narayan, SHOT Medical Director, which covers the highlights from the Annual Report, followed by a Q&A session.

Live illustrations were carried out by an artist, Jenny Leonard (image below).

A transcription and Q&A will be available soon.

Alternative video format:

SHOT Webinar – Vimeo

Live illustration from the webinar

Webinar Summary

Presentations from SHOT Symposium 2019

1. Patient experience speaker – Charlotte Silver (this presentation is unavailable)
2. What’s in the new SHOT Report for 2018 – Dr Shruthi Narayan
3. Removing blame from error and learning from excellence – Dr Adrian Plunckett (no slides available – please see useful resources at
4. Using incident reporting as a quality improvement tool – Chris Robbie

Keynote Lecture:
5. Changing behaviours and sustaining the change for safer practice – Dr Fabiana Lorencatto

Abstract winners:
6. Is the Kleihauer test still relevant in the blood transfusion laboratory – Caroline Smith
7. An effective safety net – The routine use of Intra Operative Cell Salvage for Caesarean Sections – Paul Scates

8. IT issues in transfusion – what have we learnt from incidents reported to SHOT – Dr Megan Rowley
9. Workforce planning- addressing the supply-demand challenges – Prof Jo Martin

Point-counterpoint: Debate moderated by Wendy McSporran:
9a. Do nurses need to know ABO compatibility for blood components – FOR – Sharon Hart
9b. Do nurses need to know ABO compatibility for blood components – AGAINST – Jennifer Adams


Presentations from SHOT Symposium 2018

1. Experience of therapeutic apheresis – Jo Rendall
2. Impact of a ‘never event’ in transfusion – 1 – Sue Robinson
3. Impact of a ‘never event’ in transfusion – 2 – Marie Scully (Cannot be uploaded)

Keynote Lectures:
4. Walking the tightrope – maintaining confidence in the face of errors – Trevor Dale
5. What’s in the new SHOT Report for 2017 – Paula Bolton-Maggs

6. Introduction to the Healthcare Safety Investigation Branch – Matthew Wain
7. Oops I did it again – Carol Cantwell

Abstract winner:
8. Survey of clinicians’ awareness of hazards of transfusion – Michelle Melly

9. Donor and recipient transfusion in Ghana – Veena Sharma
10. Public perception of blood – transfusion and conservation – Biddy Ridler
11. Best practice 1 Simulation training for TACO – Josephine McCullagh
12. Best Practice 2 Audit of lymphoma irradiated blood policy compliance at a UK cancer centre – Jane Gibson (Cannot be uploaded at this time)
13. TACO update – Sharran Grey
14. Challenge and response a new way of doing a bedside checklist – Kirsty Maclennan
15. Interactive cases what to do if the patient has alloantibodies and needs urgent transfusion  – Fiona Regan



Presentations from SHOT Symposium 2017

Experience of a donor – Blood Sweat & Tears – Rick Mills
Donor haemovigilance – highlights – Shruthi Narayan
SHOT: The first 15 yrs – Hannah Cohen

Keynote Lecture:
How to Be a Health Revolutionary – Phil Hammond

SHOT 2016 Report – The Oscar factor and transfusion complications – Paula Bolton-Maggs

Abstract winner:
Improving the process of obtaining patient consent and clinical documentation in blood transfusion – Keir Pickard

SHOT 2016 Report – Laboratory errors – Hema Mistry
Transfusion laboratories: The perfect storm– Debbie Asher

The Transfusion Game – Graham Oakes
Engaging with general practice – Barrie Ferguson

Debate: The motion is ‘hospitals should limit group O negative red cell use to match supply’
Introduction – Fiona Regan
FOR – Janet Birchall
AGAINST– Stephen Bassey


Presentations from SHOT Symposium 2016

The Roden family: Our survival experience – Sarah Roden
SHOT 2015 Report – Update – Dr Paula Bolton-Maggs
Keynote Lecture: Safety and Resilience – Erik Hollnagel (Denmark)
Right First Time – report from Scotland – Sandra Gray (Scotland)
Fast blood? How to communicate (or not) – Jo Lawrence (Frimley Park)
Estimating blood loss – do we get it right? – Nicki Jannaway (Truro)
Why do we need to understand complications of sickle cell disease? – Jo Howard (London)
Novel method of transfusion education for final year medical students – does it work? – Karen Shreeve (Cardiff)
Advancing TACO – Sharran Grey (Bolton)
Prevention of WBIT in intensive care – Tina Wright (Sherwood Forest)
Who am I? – Mary McNicholl (Western Health & Social Care Trust)
Safe sampling – a reliable answer? – Debbie Thomas (Truro)

To transfuse or not to transfuse? Interactive cases
A Paediatric Case – Dr Helen New
A Question of Specific Requirements – Dr Paula Bolton-Maggs

Presentations from SHOT Symposium 2015

SHOT 2014 What’s New – Dr Paula Bolton-Maggs
Towards unified haemovigilance in the UK – Update Partnership in practice – Dr Paula Bolton-Maggs
International haemovigilance – challenges and opportunities – Erica Wood
Introduction to the New ISBT Working Party on Immunohematology – Sandra Nance
International collaboration for laboratory practice – Bill Chaffe
Haemovigilance, national audit and external quality assessment – working together to improve transfusion – Megan Rowley
Donor vigilance – an international perspective – Jo Wiersum-Osselton
MHRA Partnership parallels – progressing integrated reporting and feedback – John Wilkinson
Why don’t you hear what I am saying – Jane Keidan

Presentations from SHOT Symposium 2014

SHOT update – main lessons and update from 2013 – Dr Paula Bolton-Maggs
Anti-D sensitisation – why is it still happening? – Dr Jane Keidan
Audit of Platelet Transfusion in the Belfast Trust – Dr Chris MCCauley
Human Factors – why we need to change practice – Guy Hirst
An evaluation by final year medical students of an app supporting correct use of irradiated and CMV-negative blood components – Karl Monsen
Computers as Team Players? (Slides) – Professor Harold Thimbleby
Computers as Team Players? (Narrative) – Professor Harold Thimbleby
The ICAG (Informed Consent Action Group) PAD! A regional initiative for informed consent to blood transfusion – Simon Goodwin
Interactive Cases – clinical and laboratory – Chair: Dr Fiona Regan, Discussants: Tony Davies, Terrie Perry, Dr Megan Rowley and Dr Peter Baker

Presentations from SHOT Symposium 2013

SHOT Update from the 2012 report – Dr Paula Bolton- Maggs
POCT Haemoglobin Measurement – Barbara Delasalle
TEG Rotem QC – Dianne Kitchen
FFP is it ever indicated – Jecko Thachil
Go with the flow – Tony Davies
Two samples, is it workable – Dr Jane Keidan
Two samples for cross- match – Dr Paul Kerr
Serious adverse events and their root causes – can you analyse them – Chris Robbie
Improving Practice through National Audit, National Guidelines and SHOT – Megan Rowley
Problems of 2 Samples in Paediatrics – Margaret Slade
Blood Breathlessness and bother Part 1 – Dr Hannah Cohen.pdf
Blood breathlessness and bother – Dr Catherine Chapman
Heidi Doughty’s talk – unfortunately the presentation cannot be made available, because of military rules on confidentiality

Presentations from SHOT Symposium 2012

Adverse Events in Haemoglobinopathies – Bolton-Maggs
Back To Basics – Cohen
Do You Know Who I am Update
Interactive Session H.Tinegate & D.Asher
Managing Transfusion Risk – Wallis
Massive Haemorrhage – OKeefe
Reducing Blood Transfusions – Norris Cervetto
Safer Prescribing for Junior Doctors
Transfusion Transmitted Infections – Brailsford
Unified Haemovigilance – Bolton-Maggs

Presentations from SHOT Symposium 2011

10 15 SHOT2011HC1
10.45 Sue Knowles – iU2
Dzik SHOT LECTURE for posting
14.00 Mike Murphy – SHOT2011
Interactive 1 Final Derek Norfolk
Interactive 2 Final CM
Interactive 3 Final Derek Norfolk
Interactive 4 Final CM
15.00 Liz Pirie – SHOT pres_060711
15.20 Debbie Asher presentation v3
15.40 AlisonWatt – DendriteSurvey

Presentations from SHOT Symposium 2010

SHOT data Part 1
SHOT data Part 2
TRALI TACO and the struggle for breath
Adverse events Involving IT.
The EWTD and Clinical Handover
Update on the UK Transfusion Laboratory Collaborative
Donor Adverse Event Reporting

Presentations from SHOT Symposium 2009

SHOT Part 1
SHOT Part 2
Effective Teaching
Reporting to SABRE and SHOT
Putting Guidelines into Practice
Participation in SHOT Reporting

Presentations from BBTS ASM 2008

Transfusion Related Lung Injury (TRALI): An update
Febrile Non-haemolytic Transfusion Reactions
TACO Transfusion associated circulatory overload
BCSH Guidelines for the Investigation and Management of Non-Haemolytic Transfusion Reactions

Presentations from SHOT Symposium 2008

SHOT data 2007 – Part 1
SHOT 2007 report – Part 2
SABRE reporting – 2007 statistics and future plans
What did we learn in Transfusion Microbiology in 2007?
Antenatal anti-D prophylaxis – Evidence and Guidelines
Anti-D…at the sharp end
Beyond Reason:midwives and anti D
The Blood Safety and Quality Regulations 2005 – Assessing Compliance

Presentations from SHOT meeting 2007

Non-Haemolytic Reactions
Irradiation of blood components for the prevention of transfusion-associated graft-versus-host disease
Understanding Errors and Improving Patient Safety
Out of Hours Crossmatching – 2006 Audit
When your worst fear happens…
Zooming in on Lab Errors – Debbie Asher
Zooming in on Lab Errors Clare Milkins
Little samples big problems
MHRA update
Achieving 24 7 quality
Highlights of SHOT 2006
Investigating ATRs

Presentations from SHOT meeting 2006

Highlights of 2005 report and recommendations
Near-miss reporting, what can we learn from it?
TRALI – the effect of male FFP
Where and when is blood given?
Supporting good laboratory practice
Taking forward SHOT recommendations – update of the NPSA initiative
Bedside transfusion practice – National Comparative Audit 2005
Developing Standards for transfusion
Implementing standards in healthcare

Presentations from BBTS 2005

Reflective learning and SHOT
Sharing Data as a Means to Improving Practice
Laboratory Errors Reported to SHOT

Presentations from SHOT meeting 2004

The EU Directive and Haemovigilance
Benchmarking SHOT data
Highlights from 7th SHOT report – taking SHOT recommendations forward
Transfusion errors in the laboratory – barriers to implementing safer transfusion practice
The role of MSBT
Root Cause Analysis of Transfusion Incidents – The Leeds Experience
SHOT experience and UK initiatives on TRALI prevention
The changing pattern of transfusion-transmitted infection
Transfusion errors on the wards. What can be done to prevent them?
Haemolytic Transfusion Reactions – how many are preventable?
Results from the SHOT survey of Transfusion Practitioners

Presentations from SHOT meeting 2003

FFP Safety – Where are we going?
How to prevent errors in the Transfusion Laboratory
SHOT – the future
SHOT results 2001/2002
Comments from BSH President
Root Cause Analysis in investigation of errors
Implementation of better blood transfusion practice in Scotland
SHOT and the Blood Stocks Management Scheme
Implementation of BBT2 in a Hospital Trust
National Comparative Audit of Transfusion
Blood collection and blood tracking
Sample collection and blood administration
Blood Tracking End to End
How to evaluate IT systems for the clinical transfusion process
Problems of plasma replacement in TTP