SHOT Report: Preventable Errors Continue to Drive Most Transfusion Incidents in the UK

Preventable errors accounted for 83% of all reports analyzed by the United Kingdom's Serious Hazards of Transfusion (SHOT) Program in 2025, according to the latest Annual SHOT Report. SHOT said inadequate staffing, lack of appropriate training, information technology issues and suboptimal safety culture continue to be identified as contributory factors in many reported incidents.

SHOT is the U.K.'s independent, professionally led hemovigilance program and is affiliated with the Royal College of Pathologists. In 2025, 5,147 reports were submitted to SHOT, a 2.3% increase from 2024. The annual report analyzed 4,046 cases, including incidents submitted in previous years that were finalized in 2025.

Approximately 2.16 million blood components were issued by the four U.K. blood services in 2025. The estimated risk of transfusion-related death was approximately 1 in 40,000 blood components issued, while the risk of serious harm was approximately 1 in 13,500 blood components issued.

SHOT recorded 54 transfusion-related deaths in 2025, an 8.5% decrease from 59 in 2024. Pulmonary complications, particularly transfusion-associated circulatory overload, and delayed transfusions remained the leading causes of mortality. One death was determined to be “definitely related” to transfusion following an acute hemolytic transfusion reaction.

“Near misses” remained the largest reporting category, accounting for 33.9% of all reports. SHOT said these events provide opportunities to identify weaknesses before patients are harmed but noted that the proportion of incidents resulting in no harm has continued to decline. The report said the trend suggests existing safety barriers may not be preventing errors as effectively as intended.

The report also documented eight ABO-incompatible transfusions, including five involving red blood cells and three involving plasma. SHOT attributed the red cell events to clinical errors and the plasma events to laboratory errors, saying the cases identified weak points in blood component collection and administration in the clinical area, and in laboratory component selection.

No confirmed or probable transfusion-transmitted infections were reported in 2025.

SHOT urged hospitals to implement its Transfusion Safety Standards, published in 2025 in response to recommendations from the Infected Blood Inquiry, to benchmark transfusion practices and identify targeted improvements.