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2021 Annual SHOT Report – Individual Chapters

Each chapter in the 2021 SHOT Annual Report is available below as a separate pdf file:

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

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

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

17a. Transfusion-Associated Circulatory Overload (TACO)
17b. Pulmonary Complications of Transfusion (Non-TACO)

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. Transfusion Errors in Transplant Cases
25. Immune Anti-D in Pregnancy


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