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Report, Summary and Supplement 2023

SHOT Annual Report and Summary

The SHOT Annual Report 2023 contains bookmarks for each chapter, and links to individual chapters on the Contents page. Where chapters are referenced within another chapter, there are hyperlinks to access these directly. 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:

Narayan, S. et al., 2024. The 2023 Annual SHOT Report, Manchester: Serious Hazards of Transfusion (SHOT) Steering Group. doi:


Foldable Summaries

The foldable summaries are now available to order on the following website under stock code BLC789.4


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

2023 SHOT Annual Report – Individual Chapters


Supplementary Information

Additional analysis and case studies that could not be included in the main 2023 Annual SHOT Report is included below by chapter.

Chapter 2 – Participation in UK Haemovigilance 2023
Chapter 3 – Headline Data 2023 – coming soon
Chapter 6 – Acknowledging Continuing Excellence in Transfusion (ACE) 2023 – coming soon
Chapter 7 – Donor Haemovigilance 2023 – coming soon
Chapter 8 – Human Factors and Ergonomics in SHOT Error Incidents 2023
Chapter 10 – Incorrect Blood Component Transfused (IBCT) 2023 – coming soon
Chapter 12 – Avoidable, Delayed or Under-Overtransfusion (ADU) 2023
Chapter 15 – Laboratory Errors 2023 – coming soon
Chapter 16 – Errors Related to Information Technology (IT) 2023 – coming soon
Chapter 18b – Non-TACO Pulmonary Complications 2023 – coming soon
Chapter 20 – Uncommon Complications of Transfusion (UCT) 2023 – coming soon
Chapter 21 – Transfusion-Transmitted Infections (TTI) 2023 – coming soon
Chapter 23 – Cell Salvage (CS) 2023
Chapter 27 – Immune Anti-D in Pregnancy 2023 – coming soon


2023 SHOT Recommendations Gap Analysis Tool

A Gap Analysis Tool will be developed for all SHOT reporting organisations to help identify gaps in local clinical and laboratory practices and systems to help implement the recommendations from the 2023 Annual SHOT Report and enhance transfusion safety.

The template will be 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 recommendations, and to plan and monitor continuous improvement in patient safety. Please email [email protected] with any queries relating to this.

This tool will be published in the coming weeks.