2021 SHOT Report Details Transfusion-Related Events in U.K.

July 12, 2022

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 2021, 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 2021 resembled those from previous years, but the number of reports decreased from 3,214 in 2020 to 3,161 in 2021. Errors accounted for the majority of reports (2,569 of 3,161 reports, 81.3%), a similar percentage to 2020 (81.6%). “Near-miss events” accounted for 36.5% of events reported to SHOT, increasing slightly from 1,130 in 2020 to 1,155 in 2021.

There were 35 reported deaths with various grading of imputability to transfusion (certain, probable and possible), a slight decrease from 2020 (39 deaths). TACO contributed to 11 deaths, while delays in transfusion and pulmonary non-TACO causes were reported as contributing to nine and seven deaths, respectively. Other deaths resulted from uncommon complications of transfusion (7) and hemolytic transfusion reaction (1); according to the report, 16 (45.7%) of the deaths were preventable. There were 126 cases of major morbidity. Most cases (74, 58.7%) resulted from febrile, allergic or hypotensive transfusion reactions and pulmonary complications.

There were zero ABO-incompatible red blood cell transfusions and three ABO-incompatible plasma transfusions (one each involving COVID-19 convalescent plasma, fresh frozen plasma and cryoprecipitate). All three cases reported in 2021 were due to a component selection error in the transfusion laboratory with group O plasma component being transfused to non-group O recipient.

Between 2016-21, there were 1,778 near misses where an ABO-incompatible transfusion would have resulted. Among 1,155 near-miss events in 2021, 734 resulted from wrong blood in tube (WBIT) errors. The report noted that WBIT errors cannot be detected without a previous record in the transfusion laboratory.

The report includes several key messages and recommendations to improve transfusion safety, organized through the acronym “SAFETY”: safety culture, appropriate transfusion decisions, focus on people, effective communications and documentation, training that is holistic and competency-assessment of staff involved in transfusions, and yes to safe, adequately resourced systems. The report also provides strategies for facilities and clinical transfusion staff to help improve transfusion safety.

In addition, the SHOT Report 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 0.26 per 10,000 donations and 51 SAEDs total, but the overall trend is upwards over the last 7 years. Persistent arm problems (25/51) and vasovagal reactions (10/51) were to be the most frequently reported SAEDs. There were no deaths related to blood donation in 2021.