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Report, Summary and Supplement 2020

SHOT Annual Report and Summary

The SHOT Annual Report 2020 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.

*Chapter 18 amendment – Since release of the 2020 Annual SHOT Report, it has been brought to our attention that the antibodies found during investigation for TRALI for case 18c.5 had been submitted incorrectly. The case, based on the available information at that time, had been categorised as TAD-C (Imputability- possible) but should be categorised as ‘Equivocal TRALI’. Please see the supplementary information on TRALI chapter 18a for further details*

Please cite this document as:

S Narayan (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2020 Annual
SHOT Report (2021).


Errata 2020



Foldable Summaries

The foldable summaries are now available to order on the following website under stock code blc789-1

This is a new leaflet ordering site set up in July so anyone accessing it for the first time will need to set up a new account – log-in details saved from the previous site won’t work.

Individual pdfs of each chapter can be viewed by clicking the link below:

2020 SHOT Annual Report – Individual Chapters

Supplementary Information

Chapter 2 – Participation in UK Haemovigilance 2020
Chapter 3 – Headline Data Supplementary Information 2020
Chapter 6 – Acknowledging Continuing Excellence (ACE) 2020
Chapter 8 – Human Factors 2020
Chapter 10 – Incorrect Blood Component Transfused (IBCT) 2020
Chapter 12 – Avoidable Delayed or Under-overtransfusion (ADU) 2020
Chapter 13a – Near Miss – Wrong Blood in Tube (WBIT) 2020
Chapter 15 – Laboratory Errors 2020
Chapter 18a – Transfusion-Related Acute Lung Injury (TRALI) 2020
Chapter 20 – Uncommon Complications of Transfusion (UCT) 2020
Chapter 21 – Transfusion-Transmitted Infections (TTI) 2020
Chapter 25 – Immune Anti-D in Pregnancy 2020

2020 SHOT Recommendations Gap Analysis Tool

For the 2020 Annual SHOT Report, the SHOT Team have created a Gap Analysis Tool. This 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.

2020 SHOT Recommendations Gap Analysis Tool

Previous Recommendations

Previous Key Recommendations 2002-2019