Definition
Laboratory errors encompass all SHOT reportable errors which originate in the hospital transfusion laboratory. This includes errors which primarily occur at critical laboratory steps such as sample receipt and registration, testing, component selection and component labelling, component availability and handling and storage.
For further details and examples of what to report, please visit the SHOT Definitions page.
Laboratory errors in SHOT Reporting
Errors relating to laboratory practice have been included in the Annual SHOT Report since 1997/98. Initially, these events were reported under the Incorrect Blood Component Transfused (IBCT) category. In order to better address these errors, they were assigned a dedicated chapter from 2011.
This composite chapter considers laboratory errors and near-miss events reportable under all SHOT error categories and accounts for around 20% of all errors reported to SHOT.
SHOT Transfusion Safety Standards
The SHOT Transfusion Safety Standards were released in July 2025, and these replace recommendations in the Annual SHOT Reports. More details on these can be found at: https://www.shotuk.org/transfusion-safety/transfusion-safety-standards/
Recommendations from recent Annual SHOT Reports (prior to 2024)
- Patients should not die or suffer harm from avoidable delays in transfusion. Where transfusion needs are complex, laboratory staff should have access to and follow specialist advice to provide the most suitable component available. Hospital policies and processes must reflect this
- Staff must have protected time for training and education to provide a safe service
- Bespoke operational roles should be considered for project/change implementation to ease the pressure on routine staff
- Policies for lone working should be reviewed to identify when extra support or reallocation of tasks are required
- A just and learning safety culture should be implemented to improve the safety of patients and staff members, and to ease the existing recruitment and retention pressures in the laboratory
Action: Transfusion laboratory managers
Please see the individual SHOT chapters at the end of the page for other previous recommendations which remain relevant.
Laboratory errors SHOT resources
UK Transfusion Laboratory Collaborative (UKTLC)
SHOT is proud to be a member of the United Kingdom Transfusion Laboratory Collaborative (UKTLC). The UKTLC produces minimum standards for staff qualifications, training, competency and the use of information technology in hospital transfusion laboratories. Click on the link above for more information.
Safe transfusion practices require both clinical and laboratory teams to work collaboratively and in a coordinated manner. This video has been drafted by the working expert group dealing with laboratory errors and focuses on key messages from laboratory errors reported to SHOT with important learning points and recommendations.
This meet the experts session was held on 06 March 2025. It includes a presentation with contributions from the SHOT Laboratory Incident Specialists Victoria Tuckley and Nicola Swarbrick, and SHOT Working Experts Pete Baker (Transfusion Services Manager, Liverpool Clinical Laboratories) and Heather Clarke (RCI Development Lead, NHSBT), and a Q&A session with additional contributions from UKTLC chair Kerry Dowling, UKTLC co-chair Jennifer Davies and MHRA Haemovigilance Specialist Chris Robbie.
External resources
RCI Assist – Referral Support Tool
Laboratory Errors Annual Report Chapters
To access the chapter click either on the cover of the Annual SHOT Report or the link below the picture.
