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2019 Annual SHOT Report – Individual Chapters

Each chapter in the 2019 SHOT Annual Report is available below as a separate pdf file:

1. Foreword
2. Participation in United Kingdom (UK) Haemovigilance
3. Headline Data – Deaths Major Morbidity and ABO-Incompatible Transfusions
4. Key Messages and Recommendations
5. Acknowledging Continuing Excellence (ACE) in Transfusion
6. Donor Haemovigilance

ERROR REPORTS – Human Factors

7. Human Factors in SHOT Error Incidents
8. Adverse Events Related to Anti-D Immunoglobulin (Ig)
9. Incorrect Blood Component Transfused (IBCT)
10. Handling and Storage Errors (HSE)
11. Avoidable, Delayed or Under-Overtransfusion (ADU) and Incidents Related to Prothrombin Complex Concentrates (PCC)

11a. Delayed Transfusions
11b. Avoidable Transfusions
11c. Under or Overtransfusion
11d. Incidents Related to Prothrombin Complex Concentrates

12. Near Miss (NM) Reporting

12a. Near Miss – Wrong Blood in Tube (WBIT)

13. Right Blood Right Patient (RBRP)
14. Laboratory Errors
15. Errors Related to Information Technology (IT)


16. Febrile, Allergic and Hypotensive Reactions (FAHR)
17. Pulmonary Complications – Full Chapter

17a. Transfusion-Related Acute Lung Injury (TRALI)
17b. Transfusion-Associated Circulatory Overload (TACO)
17c. Transfusion-Associated Dyspnoea (TAD)

18. Haemolytic Transfusion Reactions (HTR)
19. Uncommon Complications of Transfusion (UCT)
20. Transfusion-Transmitted Infections (TTI)


21. Cell Salvage (CS)
22. Paediatric Cases
23. Haemoglobin Disorders
24. Immune Anti-D in Pregnancy
25. Summary of Haemopoietic Stem Cell Transplant Errors 2012-2019

26. Medicines and Healthcare products Regulatory Agency (MHRA) Report