2022 SHOT Report Details Transfusion-Related Events in the UK

Transfusion delays and transfusion-associated circulatory overload (TACO) were the most common causes of transfusion-related mortality in the United Kingdom in 2022, according to the Serious Hazards of Transfusion (SHOT) annual report. Together, they accounted for 21 of 35 deaths reported to SHOT in 2022.

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 2022 were similar to those from previous years, but the number of reports increased from 3,161 in 2021 to 3,499 in 2022. As in previous years, errors accounted for the majority of reported events (2,908 of 3,499 reports, 83.1%), a slight increase from 2020 (81.3%). Of these, 7.5% were “possibly preventable” and 9.4% were “not preventable.” Near-miss events accounted for 39% of reported events, increasing from 1,155 in 2021 to 1,366 in 2022 (18%).

There were 35 reported deaths with various grading of imputability to transfusion (certain, probable and possible), the same as 2021. However, the report noted that 2022 is the first year in which transfusion delays contributed to more deaths than TACO (13 versus eight deaths, respectively). Other non-TACO pulmonary cases accounted for seven patient deaths. There were 144 cases of major morbidity. Most cases (77, 53.5%) resulted from febrile, allergic or hypotensive transfusion reactions and pulmonary complications (25, 17.4%).

In 2022, there were two patient deaths resulting from six ABO-incompatible transfusions. There were five ABO-incompatible red cell cases resulting primarily from clinical errors. The two that resulted in patient fatalities were related to blood collection errors. Of the remaining three, two were primarily due to administration errors and one was following a historical WBIT. There was one ABO-incompatible plasma transfusion this year, which resulted from a component selection error in the transfusion laboratory.  Lack of reliable, accurate patient identification was noted in the majority of these ABO-incompatible events, the report said.

While SHOT cites several factors as contributing to the increase in errors, the report notes that staffing challenges, in particular, are contributing to an increasing percentage of errors. Specifically, the report states that “a mismatch in workload and staffing levels had some impact upon over half of all laboratory incidents.” Staffing shortages also contributed to delays in transfusion and a “substantial increase” in incidents reported from the emergency department. In Chapter 4, the report includes recommendations to better support staff, optimize working efficiency and promote safety amidst challenges in the health care setting.

In addition, the report includes four key recommendations to address the common themes identified as causal or contributory to adverse events that impact transfusion safety:

• Appropriate management of anemia and making safe transfusion decisions.
• Safe systems to ensure safe transfusions.
• Effective implementation of appropriate interventions following incident investigations.
• Learning from excellence and day-to-day events.

Each key recommendation includes actions required for hospital senior management, risk management departments and clinical and transfusion laboratory staff.