The Royal College of Pathologists in the United Kingdom recently published their annual report for 2022 on the Serious Hazards of Transfusions (SHOT). The total number of whole blood donations in the U.K. in 2022 was just over 1.8 million. Although transfusions are a common and relatively safe procedure, the U.K. collects hemovigilance data on all serious adverse reactions (SAR) and serious adverse events (SAE) related to transfusions. After years of continued improvement in safety, reports of SAR and SAE in transfusions have increased two years in a row and have doubled since 2020. In the U.K. in 2022, 3499 SAR and SAE were reported, 83.1% of which were errors. “Near misses” were the most common type of report with 1366/3499 (39.0% of reports) with anti-D immunization reports (n=345) and the incorrect blood component transfused (n=296) the next two most common reports. In total, 35 patients who received transfusion support died with the leading causes being delays in transfusion (n=13) and transfusion-associated circulatory overload (TACO) (n=8). In addition, two patients died due to ABO incompatibility issues, which occurred due to a series of mistakes and shortcuts. The chair of the SHOT committee, noted the lack of improvement and stressed communication and training of staff and adherence to protocol no matter how busy or stressful the situation.
Reference:
Annual Shot Report 2022. Royal College of Pathologists.
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