SHOT participation benchmarking

SHOT has been producing participation benchmarking reports for each reporting organisation since 2010. From 2013 this data will no longer be anonymised and data for all reporting organisations will be available online to all registered reporters through the password protected link below.

Registered SHOT reporters access to view participation benchmarking data

How to use this benchmarked participation data

The quality of SHOT data can only be assured if there is adequate involvement throughout the transfusion community to ensure all incidents are reported accurately. Therefore, please use the attached data to monitor your own organisations level of participation in the SHOT scheme in comparison to organisations of similar usage. The results for an individual organisation should be interpreted with caution, based on knowledge of your local transfusion practice. If your organisation submitted more reports than similar organisations, then this may either reflect a real problem with transfusion safety, or alternatively that you are better at recognising and reporting transfusion-related reactions and adverse events. On the other hand if your organisation submitted fewer reports than similar organisations, then this may either reflect good practice or could be that reactions and adverse events are under-recognised and under-reported.

Reporting organisations have been grouped in two separate ways:

• Clustered by size according to the number of blood components issued to the Trust/Health Board (issue data used as a surrogate for usage data)
• Geographically, by UK country and where applicable, grouped according to their Regional Transfusion Committee (RTC)

There are comparative data charts within each usage cluster and geographical group to enable an individual organisation to benchmark itself against its peers.

Data has been subcategorised into the main incident types:

• Serious Adverse Reaction (broadly equivalent to unpredictable clinical reactions)
• Serious Adverse Event (broadly equivalent to avoidable errors)
• Near Miss – Other
• Near Miss – Wrong Blood in Tube (WBIT)
• Anti-D
• Withdrawn
• Other (= uncommon incidents such as transfusion-transmitted infections)

New for 2022 – analysis of febrile reactions

Number of febrile reactions reported
Number where inappropriate treatment was given

Febrile reactions to transfusion should not be treated with an antihistamine or steroid. The annual participation report for each Trust/Health Board will now include the total number of reactions submitted with purely febrile/inflammatory symptoms and the number of those inappropriately managed with antihistamine or steroids. Teams are encouraged to use this information to guide local audit and education. Please see associated resources – SHOT Bite No. 5 – FAHR and video FAHR – Febrile, Allergic and Hypotensive Reactions for more information on managing transfusion reactions.

SHOT conducted a user survey in 2019, and as a result of feedback from this, the ‘Near Miss’ data has been split between WBIT and other types of near miss for 2019 data onwards. To view the survey results, click here.

All data are presented as number of SHOT reports per 1,000 blood components issued or per 100 units of anti-D immunoglobulin (Ig) issued. This allows a more accurate comparison between organisations of different sizes. A caveat to the data analysis on anti-D Ig reports is that SHOT rely on the hospitals to submit accurate data. Sometimes no data is supplied or data is incomplete, for example where there are multiple sites within a Trust/Health Board, but not all sites provide data.

Data are presented in the following formats:

1. Individual summary table

Each reporting organisation will receive a report, subcategorised into the main incident types, containing:

• The organisation’s code number, so your organisation’s data can be identified in the comparison charts
• Total number of reports submitted in the year 2023 and a comparison with the previous year ‘Increase/decrease from 2022’
• Average number of reports for the relevant UK-wide blood component usage group (see item 2 below)
• Average number of reports for the relevant geographical area (see item 3 below)
• Total number of 2023 reports submitted expressed as per 1,000 blood components issued or per 100 units of anti-D Ig used, plus a comparison with the previous year ‘Increase/decrease from 2022’
• Average reports per 1,000* for the relevant geographical area (per 100 for Anti-D Ig) Average reports per 1,000 for the relevant component issue cluster (*per 100 for Anti-D Ig)
• Number of febrile reactions reported
• Number where inappropriate treatment was given

There are a few organisations with such low component usage (less than 1000 components per annum) that meaningful benchmarked comparisons are not feasible. These organisations will receive only the summary table report and will not be featured on the comparison graphs.

2. Total reports by usage size of organisation

A graphical representation of the total reports submitted by all organisations within a usage cluster. Organisations have been allocated to a cluster according to total blood components issued to that organisation per annum. These clusters are similar to, but not identical to those used by the Blood Stocks Management Scheme (BSMS). From 2018 data the boundaries between usage categories have been reduced. This is because as component usage falls, more and more organisations were moving to the low and medium usage category, which meant there were too many organisations to display a meaningful graph. This change ensures a more even split between usage categories.

• Very low: up to 1,000 components received per annum
• Low: 1,001-6,000 components received per annum
• Medium: 6,001-10,000 components received per annum
• High: 10,001-19,000 components received per annum
• Very high: >19,000 components received per annum

3. Reports by geographical location

A graphical representation of the total reports submitted by all organisations within a geographical area defined as either the devolved UK country or the RTC.

4. A summary of participation levels for all RTC areas and devolved countries

A graphical representation of the total reports submitted by each devolved UK country or RTC.

SHOT Participation Benchmarking data has been de-anonymised for a number of years, and this data may also be shared with other NHS organisations with a patient safety role, such as the CQC and NHS Improvement. Any shared data is intended for internal use between the NHS body and the reporting organisation only and will never be shared outside these boundaries.

Frequently asked questions

Answers to some common questions about the SHOT Participation Benchmarking project have been compiled in the document below.

SHOT Participation Benchmarking FAQs