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Report and Summary 2004

Please click on the links to download the pdf files.

Summary 2004 (pdf)
SHOT Report 2004 (pdf)

Please cite this document as:

Stainsby D (Ed.), Jones H, Boncinelli A, et al, on behalf of the Serious Hazards of Transfusion (SHOT) Steering
Group. The 2004 Annual SHOT Report (2005).

SHOT Erratum 2004
Page 24, IBCT chapter, bottom of page
Please note that the last learning point on this page was omitted from the printed version.
This version only should be used.

Learning points

  • Correct procedures must be followed for patient sampling
  • A decision to transfuse must be based on clinical assessment as well as laboratory results – look at the patient!
  • Blood components must not be given without prescription
  • Blood should only be prescribed by a doctor who has undergone training in blood transfusion and has been assessed as competent
  • Diagnostic laboratories must carry out checks to identify large changes in parameters (‘delta checks’) and should not issue unvalidated reports
  • Nurses giving blood must familiar with blood components and the indications for their use
  • Transfusion laboratory staff should be empowered to challenge inappropriate requests. This will require agreed protocols and training.

Near Miss Table
Report 2004, page 30
Staff involved in “near miss” incidents (n=1076)
Breakdown of staff which fall into the ‘other’ category in the main report (n=32)

Staff groupNumber of incidents involving each staff group
A&E team3
Taxi driver/courier2
Clinical fellow1
Health care assistant5
Bed manager1
Operating department assistant4
Student midwife1
Support worker6
Surgical assistant1
Theatre team6
Ward auxillary2

Cumulative Data
SABRE communication Oct 2008 v 3

SHOT Recommendations
Recommendations for British Blood Transfusion Society
Recommendations for British Committee for Standards in Haematology
Recommendations for Chief Medical Officer’s National Blood Transfusion Committee
Recommendations for Consultant Haematologists
Recommendations for Department of Health
Recommendations for Hospital Staff Involved in the transfusion process
Recommendations for Hospital Transfusion Committees
Recommendations for Hospital Transfusion Laboratories
Recommendations for Hospital Transfusion Teams
Recommendations for NPSA/SHOT/NBTC Initiative
Recommendations for Primary Care Trusts
Recommendations for Professional & Accrediting bodies
Recommendations for Regional Transfusion Committees
Recommendations for Strategic Health Authorities
Recommendations for Trust Chief Executive Officer’s
Recommendations for Clinical Directors of Pathology
Recommendations for UK Blood Services