2020 SHOT Report Details Transfusion-Related Events in U.K.

August 04, 2021

Non-infectious complications, particularly delays in transfusion and transfusion-associated circulatory overload (TACO), were the most common causes of transfusion-related deaths in the United Kingdom in 2020, according to the Serious Hazards of Transfusion (SHOT) Annual Report. SHOT is the U.K.’s independent, professionally led hemovigilance program and is affiliated with the Royal College of Pathologists. Since 1996, SHOT has collected and analyzed information on adverse events and reactions in blood transfusion from almost all of the health care organizations involved in the transfusion of blood and blood components in the U.K.

The pattern of reports in 2020 resembled those in previous years, but the number of reports decreased from 3,397 in 2019 to 3,214 in 2020. Errors continue to account for the majority of reports (2,623 of 3,214 reports), although the percentage related to errors decreased from 84.1% in 2019 to 81.6% in 2020. “Near-miss events” accounted for 35.2% of events reported to SHOT, decreasing from 1,314 in 2019 to 1,130 in 2020. The overall percentage of near-miss events compared to total SHOT reports also decreased, with 2020 being the lowest percentage in the last 10 years.

There were 39 deaths with various grading of imputability to transfusion (certain, probable and possible), a steep increase compared to 2019 (17 deaths). TACO contributed to 18 deaths, while delays in transfusion contributed to 12 deaths. Other deaths resulted from transfusion-associated dyspnea (4) uncommon complications of transfusion (3), undertransfusion (1) and transfusion-related acute lung injury (1). According to the report, COVID-19 appears to have contributed in some degree to the increase in transfusion-related deaths, being implicated as a co-morbidity in 5 TACO cases, but was not notable in cases of delayed transfusion. There were 137 cases of major morbidity. Most cases resulted from febrile, allergic or hypotensive transfusion reactions and pulmonary complications.

There were 7 ABO-incompatible red blood cell transfusions, 1 ABO-incompatible fresh frozen plasma transfusion and 1 ABO-incompatible convalescent plasma transfusion reported in 2020. Between 2016-20, 19 ABOi red cell transfusions, there were 1,495 near misses where an ABO-incompatible transfusion would have resulted. Among 1,130 near-miss events in 2020, 673 resulted from wrong blood in tube (WBIT) errors. The report noted that these errors cannot be detected without a previous record in the transfusion laboratory.

The report also detailed key recommendations to improve transfusion safety. In particular, the report outlines actions to prevent transfusion delays, which are increasing year on year and largely avoidable. The report also advised that effective and reliable transfusion information technology (IT) systems are implemented to reduce the risk of errors at all steps in the transfusion pathway. Additionally, the report recommended the effective investigation of all incidents and near miss events, the application of effective corrective and preventive actions, and measuring the effectiveness of these interventions to optimize learning from these incidents.

The SHOT Report also summarized findings from the U.K. donor hemovigilance program. The overall incidence of serious adverse event of donation (SAED) remains low, with a rate of 0.22 per 10,000 donations and 38 SAEDs total. Persistent arm problems (17/38) and vasovagal events (12/38) continue to be the most frequently reported SAEDs. Vasovagal events and bruising were more common in COVID-19 convalescent plasma (CCP) donors by both whole blood and plasmapheresis compared with regular whole blood and platelet donors. There were no deaths related to blood donation.