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SHOT was born from an idea for a central body collecting and analysing reports of adverse events and reaction relating to blood transfusion
The national coordinator was Dr Elizabeth M Love and the writing group consisted of 8 experts in the filed of transfusion. Dr Hannah Cohen was chair of the Steering Group.
The report was paper based and mainly covered reactions.
94 (22.1%) hospitals submitted 169 reports. The most common category of reports was Incorrect Blood Component Transfused (47%).
SHOT at 2 years old - led by Dr Elizabeth Love with a writing group of 11 experts. Dr Hannah Cohen was chair of the Steering Group.
The report was available on paper and as a pdf file, IBCT was biggest category (56%)
424 Hospitals registered with the scheme, 276 hospitals submitted 197 reports or stated nil return showing 65% participation rate.
Project initiated to collect near miss events.
SHOT at 3 years old - led by Dr Elizabeth Love with a writing group of 11 experts. Dr Hannah Cohen was chair of the Steering Group.
The report was available on paper and as a pdf file, IBCT still the largest category (57.3%)
432 hospital eligible to participate, 132 (30.6%) submitted results and a further 204 sent 'nil to report', participation now running at 77.8%.
Workshop convened to progress the recommendation for a bedside check to reduce the risk of IBCT. Workshop: Improving the safety of Blood Transfusion at the Bedside - Manchester Blood Centre 30 September 1999. Speakers included: Dr Elizabeth Love, Dr Mike Murphy, Dr Brian McClelland, Colin Clark, Mike Wilks, Lyn Sharman, Ian Cumming, Prof. Alistair Bellingham.
Health Service Circular 19981224 “Better Blood Transfusion” requires hospital Trusts to participate in SHOT reporting.
SHOT at 4 years old - led by Dr Elizabeth Love with a writing group of 11 experts. Dr Hannah Cohen was chair of the Steering Group.
The report was available on paper and as a pdf file, IBCT still the largest category (69.1%)
426 hospitals eligible to participate, 155 submitted reports and 150 'nil to report', participation 72%. A formal mechanism to monitor participation not in place but the Advisory Committee for Clinical Pathology Accreditation addressing how best to incorporate SHOT participation within CPA standards.
“WRONG BLOOD INCIDENTS ARE WITHOUT EXCEPTION AVOIDABLE ERRORS”
The report contained a section on the experience with electronic systems to control the clinical transfusion process. A handheld computer device had been developed and piloted using barcodes on patient ID bands, blood samples and blood packs. This system was to be tested in 2001 at the John Radcliffe Hospital, Oxford and Morriston Hospital in Swansea.
This section, written by Dr Derek Norfolk, stated 'Computer-based systems, employing technology for positive identification, will soon control the clinical transfusion process “from vein to vein”. It is essential that clinical units work closely with manufacturers to develop systems of high clinical utility and acceptability. Transfusion is only one of many exciting possibilities for the use of these technologies to improve the safety of clinical systems'
SHOT at 5 years old - led by Dr Elizabeth Love with an 11 strong writing group. Dr Hannah Cohen was chair of the Steering group.
The report was available on paper and as a pdf. 315 reports submitted, IBCT still the largest category with 213/315 (67.6%).
413 hospitals eligible to participate, 199 submitted reports and 180 indicated no incidents, participation running at 91.8%.
The report quoted - The Organisation With a Memory [Department of Health 2000 (www.doh.gov.uk) should learn how to avoid making the same mistake twice – and it should also be equipped to act, consistently so that it really does not repeat its errors.
The UK’s new National Patient Safety Agency (NPSA) stressed that “Improvement strategies that punish individual clinicians are misguided and do not work. Fixing dysfunctional systems on the other hand is the work that needs to be done”.
The report also noted that Transfusion Nurses were the way forward and support the Transfusion Nurse Specialist role.
SHOT at 6 years old - led by Dr Dorothy Stainsby and Ms Katy Davison, 10 colleagues on the writing group. Dr Hannah Cohen was chair of the Steering Group.
The report was available on line and as a pfd. 478 reports submitted, IBCT the highest category with 258 reports (71.7%)
405 hospitals eligible to participate, 187 submitted reports, 191 hospitals stated they had seen no incidents. Participation at 93.3%.
Large increase noted in TRALI reports, mainly caused by FFP. SHOT recommended that UK Transfusion Services should evaluate available options (e.g. sourcing of FFP from untransfused male donors, suspension of platelets in plasma-free medium), and take all steps possible to reduce the risk of TRALI from blood components.
Report noted that there was a need for a 'national body to advise government on priorities for transfusion safety' and that 'poor communication was an important cause of adverse events'.
Report noted risk of bacterial contamination from platelets and recommended 'implementation of diversion of the first few mL of the donation (likely to contain any
organisms entering the collection needle from the venepuncture site) and improvements in cleansing of donors’ arms. Methods for testing platelets for bacterial contamination should be evaluated'
The last year that the reporting year ended in September, from 2003 the reporting year would be January to December.
SHOT at 7 years old - led by Dr Dorothy Stainsby and Ms Katy Davison, 14 people on the writing group. Dr Hannah Cohen was chair of the Steering Group.
The report was available on paper and as a pdf. 480 reports received, 358 were IBCT (75%).
415 hospitals eligible to participate, 351 (85%) returned cards stating they had participated.
The report stated 'Evidence of participation is required for the Clinical Negligence Scheme for Trusts (CNST) and may be required for other accreditation schemes. Reporting of adverse reactions to blood transfusion will become mandatory with implementation of the EU Directive'.
SHOT at 8 years old - led by Dr Dorothy Stainsby and Ms Katy Davison. 11 people on the writing group and SHOT now have 2 office staff, Ms Hilary Jones (Scheme Manager) and Mrs Aysha Boncinelli (Data Collection Specialist). Dr Hannah Cohen was chair of the Steering Group.
The report was available on paper and as a pdf. 541 reports, 439 were IBCT (wrong blood incidents)
'With the adoption in 2003 of confidential identification numbers, SHOT is now able to provide every hospital with verification of participation, required in England for the Clinical Negligence Scheme for Trusts (CNST). In 2004, 218/405 (54%) of hospitals reported incidents, compared with 47% last year. When “near misses” are included, this figure rises to 270/405 (67%)'.
'There were no confirmed reports of bacterial infection by transfused components'.
Recommendations included 'An open learning and improvement culture must continue to be developed in which SHOT reporting is a key element'
'A questionnaire survey of implementation of 'Better Blood Transfusion' in England and Wales conducted in April 2004 [Murphy M, personal communication] indicated that 70% of NHS Trusts responding had a HTT that included a Transfusion Practitioner, but only 30% had administrative support'.
'Appropriate use of blood components must be strenuously promoted and evaluated'.
SHOT at 9 years old - led by Dr Dorothy Stainsby and Ms Katy Davison. Writing group included 16 people, Dr Hannah Cohen was the chair of the Steering Group.
The report was available on paper and pdf. Two hundred and seventy-nine of 403 eligible hospitals in the UK submitted at least one appropriate report, or near miss,
giving an overall participation rate of 69%.
Near miss reporting continued to increase, as in previous years, patient mis-identification at the blood sampling stage resulting in ‘wrong blood in tube’ was the most
frequently reported event, accounting for 574/1358 (42.2%) of reports.
The Blood Safety and Quality Regulations were noted as future developments in haemovigilance.
SHOT at 10 years old - led by Dr Dorothy Stainsby and later by Dr Clare Taylor. The SHOT office team now has a Scheme Manager (Mrs Hilary Jones), a Data Collection Specialist (Mrs Aysha Boncinelli), and a Transfusion Liaison Practitioner (Anthony Davies) . The writing group has 13 people and Dr Hannah Cohen was the chair of the Steering Group.
The report was available on paper and as a pdf. IBCT accounted for 75% of reports but almost 50% of cases in this category were not strictly speaking relating to ‘incorrect blood
component transfused’ but to correct blood components being given incorrectly, or handled incorrectly. The report stated that 'with additional staff and new IT, SHOT will be in a position to respond to the changing pattern of reporting and to analyse the data in a way that reflects this and utilises the enormous wealth of information to the full'. New developments in reporting were made to anti-D, near miss, TACO, cell salvage,and inappropriate or unnecessary transfusion.
The MHRA reporting portal SABRE had been in place for MHRA and SHOT since November 2005. First year of electronic data collection for SHOT.
SHOT at 11 years old - led by Dr Clare Taylor, with the SHOT team of Hilary Jones, Tony Davies and Lisa Brant and were welcoming an Operations Manager Mr David Mold. Further additions to the SHOT team, a clinical and a laboratory incident specialist were being planned.The writing group had 11 people and Dr Hannah Cohen was the chair of the Steering Group.
The report was paperbased and pdf.
Themes included the importance of training and education, and the report noted that the 'National Patient Safety Agency Safer Practice Notice (NPSA SPN) 14 , which is to be fully completed by November, 2010, will reduce errors in phlebotomy, blood component collection and administration'.
The SHOT-initiated National Transfusion Laboratory Collaborative produced evidence-based recommendations. These are around laboratory automation and staffing numbers, skill mix and qualifications, and include both short- and longterm recommendations. It is imperative that appropriate resource becomes available to correct the current deficiencies, which are increasing risk for patients.
SaBTO was a newly established advisory committee on Safety of Blood Tissues and Organs that had replaced the previous advisory committee MSBTO (Microbiological Safety of Blood Tissues and Organs).
The report format was updated to include a paediatric section, a separate analysis of IT-related IBCT cases and laboratory-related IBCT cases following the main IBCT chapter. Also included were chapters on autologous transfusion and TACO.
1042 cases were submitted but non-participation remained a concern. 561 reports were reviewed, with IBCT still making the highest proportion (59.1%).
SHOT at 12 years old - led by Dr Clare Taylor with the SHOT team (David Mold, Hilary Jones, Tony Davies and Lisa Brant). Steering group chaired by Dr Hannah Cohen.
Large increase in the number of cases reviewed, at 1040, thought to be the result of familiarity with the requirements of BSQR.
The report was paperbased and pdf.
SHOT reporting was a requirement of Clinical Pathology Accreditation Ltd, United Kingdom (CPA UK).
This year inappropriate and unnecessary transfusion and handling and storage errors were removed from IBCT into separate stand-alone categories and chapters. TACO became a specific category, as well as transfusion-associated dyspnoea (TAD). A chapter on participation was introduced.
SHOT contracted Dendrite Clinical Systems to provide a process for web-based data collection.
SHOT at 13 years old - led by Dr Clare Taylor, the SHOT team of David Mold, Hilary Jones, Lisa Brant and Tony Davies, have now been joined by a laboratory incident specialist (Mrs Hema Mistry) and a clinical incident specialist (Mrs Julie Ball). Dr Hannah Cohen chaired the steering group.
The report was paperbased and pdf.
1279 reports were analysed. The trends in reporting noted a hallmark of an effective vigilance system, in that the participation in the scheme, and thus total reports, increases as users become engaged with the process while the number of serious incidents declines. Since the reconfiguration of the IBCT category, ATR now holds the highest proportion of reports with 31.3%.
Participation data was broken down into regions of the UK.
IT, patient identification and handover featured in the recommendations.
The recommendations of the UK Transfusion Laboratory Collaborative, which SHOT initiated and in which SHOT is a main collaborator, have been sent to all laboratory and service managers as well as Trust/hospital chief executive officers in England, Wales and Northern Ireland and other stakeholders.
The SHOT website was updated, allowing the team to control the content and providing a secure login page for the Steering Group and Working Expert Group members.
SHOT at 14 years old - led by Dr Sue Knowles as interim Medical Director. Ms Alison Watt became the Operations Manager and Debbi Poles joined the team as a Research Analyst, taking over from Hilary Jones. Ms Clare Reynolds took over from Lisa Brant. Tony Davies, Julie Ball and Hema Mistry remained in the team.
Dendrite was introduced on the 4 January for online reporting, including near miss events.
The report was available in paper and as a pdf on the website.
First year with no confirmed cases of TTI, there was a 29% reduction overall in the number of incorrect blood component transfused (IBCT) reports: 57% less in the clinical area and 28% less in the laboratory.
The report now includes a summary of mortality and morbidity, an analysis of near miss incidents, and a chapter related to the definitions of donor adverse events.
1464 reports were analysed, with ATR again holding the highest proportion (34.8%).
Death or serious harm as a result of the inadvertent transfusion of ABO-incompatible blood components was included in the Department of Health 'never events' list.
SHOT at 15 years old - led by Dr Paula Bolton-Maggs. Mrs Christine Gallagher joins Hema Mistry as laboratory incident specialist and Dr Su Brailsford joins the team.
The report is available on the website.
Participation rate has reached 98.4% of NHS hospitals, Trusts and Health Boards across the UK.
The report includes a section from the MHRA and work has begun on investigating to what extent the tow haemovigilance systems can be harmonised.
ATR provides the largest category of pathological and unforeseen events (32.3%), and are the leading cause of major morbidity.
Future reporting is being considered to include immune anti-D detected in pregnancy and errors in PCC.
SaBTO published their recommendations on consent for blood transfusion in October 2011.
SHOT at 16 years old - led by Dr Paula Bolton-Maggs, Dr Dafydd Thomas joins the team as the Steering Group Chair.
The report is available on the website along with supplementary material.
2466 cases analysed, including 1 death from TA-GvHD, the first seen since 2001. The proportion of reported incidents due to error remains high, at 62.4% (1026/1645), excluding reports of ‘right blood right patient’ and ‘near miss’ events.
The name of the category ‘Inappropriate and Unnecessary’ was changed to ‘Avoidable, Delayed or Undertransfusion (ADU)’ to capture delays and inadequate transfusions in addition to those that should have been avoided (inappropriate and unnecessary).
Mild reactions are no longer collected.
Reporting for immune anti-D in pregnancy was introduced.
Human Factors in hospital practice is introduced to the report.
SHOT at 17 years old - led by Dr Paula Bolton -Maggs with Dr Dafydd Thomas as Steering Group Chair, the SHOT team and Ms Claire Reynolds joining the group.
The report was available on the website along with supplementary material.
2751 cases analysed, there continues to be a large number of instances of ‘specific requirements not met’ in haematology. This is most commonly failure to request irradiated cellular components for patients at risk, emergency departments are at risk for delayed or avoidable transfusions.
Reporters are encouraged to report cases of hyperhaemolysis.
The National Institute for Health and Care Excellence (NICE) is developing transfusion guidelines and Professor Mike Murphy is chair of this guideline group.
SHOT at 18 years old - led by Dr Paula Bolton-Maggs with the SHOT team and Dr Dafydd Thomas as chair of the Steering Group.
The report is available on the website with supplementary material.
Following the continued observation that the majority of reports follow mistakes (often multiple) in the transfusion process (77.8%) we have included a chapter on human factors to examine some of these.
3017 cases analysed.
A survey was designed and distributed to 21 volunteer participants representing different hospitals/Health Boards across England, Wales and Scotland to see what successes or difficulties/challenges they experience when attempting to implement SHOT recommendations published between 2011 and 2013.
SHOT at 19 years old - led by Dr Paula Bolton-Maggs with a Working Expert Group and Writing Group. Dr Dafydd Thomas was Steering Group Chair. The SHOT team were joined by Mrs Jayne Addison as Patient Blood Management Practitioner and Ms Joanne Bark as Laboratory Incident Specialist. Mrs Rachel Morrison joined the team.
The report is available on the website
3965 reports submitted, only 4 NHS Trusts/Health Boards did not submit reports. Errors accounted for 77.7% of all reports.
Phase 1 of changes were made to the MHRA SABRE database. The changes included removal of the share with SHOT and SHOT only options, so all cases, including all Serious Adverse Events (SAE) could be seen by both organisations, enabling better harmonisation and data reconciliation
The new SHOT website was launched.
Tony Davies Patient Blood Management Practitioner/SHOT retired.
SHOT Bites were launched.
SHOT at 20 years old - led by Dr Paula Bolton-Maggs with a Working Expert Group and Writing Group. Dr Dafydd Thomas was Steering Group Chair. The SHOT team was joined by Mrs Rachael Morrison.
The report is available on the website.
3634 reports submitted with only one NHS organisation not submitting.
Errors accounted for 87.0% of all reports.
The updated National Indication Codes were incorporated into the SHOT questionnaires.
3091 total reports were included in the Annual Report.
Annual SHOT Symposium was held at The Lowry, Manchester.
Reporting HEV cases was introduced for incidents where a patient’s HEV-specific requirements were not met.
SHOT introduced some Human Factors (HF) questions into the SHOT database (Dendrite).
An anniversary message from Doctor Alison Watt, SHOT Human Factors Expert
SHOT at 21 years old - led by Dr Paula Bolton-Maggs with a Working Expert Group and Writing Group. Professor Mark Bellamy now Steering Group Chair. Mr Simon Carter-Graham and Mrs Ann Fogg join the SHOT team as Clinical Incident Specialists.
The report is available on the website
3959 reports submitted, small number of small facilities not submitting reports.
Errors account for 85.5% of reports.
The Annual SHOT Symposium was held at The Lowry, Manchester
The Human Factors (HF) Tuition Self-Learning Package was created to help reporters consider the HF aspects in their adverse incidents
Phase 2 to harmonise reporting and reduce duplication between MHRA and SHOT went live. This introduced a link from SABRE directly into the SHOT database (Dendrite), enabling reporters to use a single log-in to report to both the MHRA and SHOT
Dr Daffyd Thomas stepped down as Chair of SHOT Steering Group and Professor Mark Bellamy was welcomed as his replacement
SHOT at 22 years old - led by Dr Paula Bolton-Maggs and Dr Shruthi Narayan with a Working Expert Group and Writing Group. Professor Mark Bellamy was Steering Group Chair. Ms Courtney Spinks takes over from Alison Watt as Operations Manager and Mr Joe Flannagan joins the team.
The report is available on the website.
Participation remains high, with only 3 NHS Trusts/Health Boards not submitting reports.
4037 reports submitted, errors account for 87.3% of reports.
Dr Paula Maggs retired as SHOT Medical Director and Dr Shruthi Narayan was instated
The Annual SHOT Symposium was held at in Harpenden, Hertfordshire
SHOT at 23 years old - led by Dr Shruthi Narayan with a Working Expert Group and Writing Group. Professor Mark Bellamy was Steering Group Chair. Ms Emma Milser joins the team as Patient Blood Management Practitioner, and Victoria Tuckley joins as a Laboratory Incident Specialist.
The report is available on the website.
4248 reports submitted, only 3 organisations did not submit reports.
Errors make up 84.1% of reports.
The Annual SHOT Symposium was held at The Lowry, Manchester
The Acknowledging Continuing Excellence (ACE) chapter was introduced to recognised exceptional practice
SHOT at 24 years old - led by Dr Shruthi Narayan with a Working Expert Group and Writing Group. Professor Mark Bellamy was Steering Group Chair.
The report is available on the website.
4063 reports submitted, with only 2 organisations not submitting reports.
Errors account for 81.6% of reports.
COVID-19 strikes!
The COVID-19 pandemic marked accelerated innovation and transformation for SHOT as the team adapted to remote working, and education was delivered virtually.
The Annual Symposium was replaced with a Webinar using the Zoom platform.
SHOT worked closely with the NHSBT Clinical Trials Unit on Convalescent Plasma clinical trails in the UK.
The SHOT App was launched.
A series of Webinars were held by the SHOT Team with relevant WEG members and SHOTcasts were launched.
The Human Factors Investigation Tool (HFIT) was reviewed and updated incorporating the Yorkshire Contributory Factors Framework.
SHOT videos were released covering Human Factors and ABOi transfusions.
SHOT at 25 years
SHOT was shortlisted for a Patient Experience Network National Award in 2021 in the Measuring, Reporting and Acting category.
Let's celebrate!
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