Annual SHOT Report
The SHOT Annual Report 2021 contains bookmarks for each chapter, and links to individual chapters on the Contents pages. These enable you to easily navigate to the chapter you require.
The electronic pdf below contains the web only MHRA chapter. This does not appear in the printed version.

Please cite this document as:
S Narayan (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2021 Annual SHOT Report (2022).
Annual SHOT Report Foldable Summaries
The Annual SHOT Report summary is available to view by clicking either the image or the link below:
Annual SHOT Report Summary 2021
The foldable summaries are now available to order on the following website:
NHS LeafletsAnnual SHOT Report Individual Chapters
The Annual SHOT Report is available as individual chapters by clicking below:
Chapter 1 Annual SHOT Report Foreward 2021
Chapter 2 Participation in United Kingdom (UK) Haemovigilance 2021
Chapter 3 Headline data – Deaths, Major Morbidity and ABO-incompatible Transfusions 2021
Chapter 4 Key Messages and Recommendations 2021
Chapter 5 Acknowledging Continuing Excellence (ACE) 2021
Chapter 6 Donor Haemovigilance 2021
ERROR REPORTS
Chapter 7 Human Factors in SHOT Error Incidents 2021
Chapter 8 Adverse Errors Related to Anti-D Immunoglobulin (Ig) 2021
Chapter 9 Incorrect Blood Component Transfused 2021
Chapter 10 Handling and Storage Errors 2021
Chapter 11 Avoidable, delayed and Under/Overtransfusion (ADU) 2021
Chapter 11a Delayed Transfusions 2021
Chapter 11b Avoidable Transfusion 2021
Chapter 11c Under or Over Transfusion 2021
Chapter 11d Incidents related to Prothrombin Complex Concentrate (PCC) 2021
ERROR REPORTS WITH NO HARM
Chapter 12 Near Miss Reporting 2021
Chapter 12a Near Miss – Wrong Blood in Tube (WBIT) 2021
Chapter 13 Right Blood Right Patient (RBRP) 2021
ERROR REPORTS COMPOSITE CHAPTERS
Chapter 14 Laboratory Errors 2021
Chapter 15 Errors Related to Information Technology 2021
REACTIONS IN PATIENTS
Chapter 16 Febrile, Allergic and Hypotensive Reactions (FAHR) 2021
Chapter 17 Pulmonary Complications 2021
Chapter 17a Transfusion Associated Circulatory Overload (TACO) 2021
Chapter 17b Pulmonary Complications of Transfusion non-TACO 2021
Chapter 18 Haemolytic Transfusion Reactions (HTR) 2021
Chapter 19 Uncommon Complications of Transfusion (UCT) 2021
Chapter 20 Transfusion Transmitted Infection (TTI) 2021
Chapter 21 Cell Salvage (CS) 2021
SPECIAL CLINICAL GROUPS
Chapter 22 Paediatric Cases 2021
Chapter 23 Haemoglobin Disorders 2021
Chapter 24 Transfusion Errors in Transplant Cases 2021
Chapter 25 Immune Anti-D in Pregnancy 2021
Chapter 26 Medicines and Healthcare Regulatory Agency (MHRA) Report 2021
Resources from the 2021 Annual SHOT Report
Use of SHOT resources:
The downloadable documents are the property of SHOT and have SHOT copyright. They must therefore NOT BE MODIFIED without permission.
Cases from the 2021 Annual SHOT Report
Figures from the 2021 Annual SHOT Report
Supplementary Information
Chapter 2 – Participation in UK Haemovigilance 2021
Chapter 3 – Headline Data 2021
Chapter 7 – Human Factors 2021
Chapter 9 – Incorrect Blood Component Transfused (IBCT) 2021
Chapter 11 – Avoidable, Delayed or Under-Overtransfusion (ADU) 2021
Chapter 12a – Near Miss – Wrong Blood in Tube (WBIT) 2021
Chapter 17b – Non-TACO Pulmonary Complications 2021
Chapter 22 – Paediatric Cases 2021
Chapter 25 – Immune Anti-D in Pregnancy 2021
2021 SHOT Recommendations Gap Analysis Tool
The Gap Analysis Tool is designed to help SHOT reporting organisations to easily audit their position on SHOT Recommendations – identifying the extent to which they are already compliant, whether there are any existing gaps, and the best ways to bridge those gaps.
The template has been pre-formatted with the SHOT Recommendations. The Gap Analysis Tool includes an Action Plan, allowing organisations to record, in narrative form, comparison of current services against SHOT Recommedations, and to plan and monitor continuous improvement in patient safety.