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Serious Hazards of Transfusion

April 10, 2024

Serious Hazards of Transfusion (SHOT) is the United Kingdom's haemovigilance scheme.

It collects and analyses anonymized information on adverse events and blood transfusion reactions. When SHOT has identified risks related to transfusion, it produces recommendations within its annual reports to improve patient safety. These reports are freely available on its website.

SHOT, together with the Medicines and Healthcare products Regulatory Agency (MHRA), works to support haemovigilance reporting in the UK.

Results edit

SHOT's statistical data has been used to decrease bacterial infections through better skin cleansing procedures and the incidence of life-threatening transfusion-related acute lung injury (TRALI) in the UK, by discouraging the use of fresh frozen plasma from female donors.[1] The cause of TRALI is not fully understood, and may have more than one mechanism,[2] but most cases are associated with transfusion of plasma or other blood products that contain some antibodies that the donor developed during pregnancy.[3][4] Not using plasma donation from female donors for transfusions eliminates the risk of exposing the recipient to pregnancy-related antibodies, and therefore reduces the risk of TRALI.[4] The collected information has also provided evidence to support the pre-existing practice of leukodepletion (depleting the number of leukocytes, or white blood cells, from the product) to reduce the risk of transfusion-associated graft-versus-host disease and post-transfusion purpura in immunocompromised patients.[1]

SHOT's data has also focused attention on human errors, with the result that staff training and procedures have been improved. For example, SHOT's data demonstrated that increasing the use of wristbands for patient identification and portable, bedside barcode readers reduced the risk of an error caused by human factors.[1]

History edit

SHOT was established in 1996.[5] During the first ten years, it collected more than 2,000 confidential reports about transfusion safety problems or near misses.[5] During the first two years of voluntary reports, about half of these errors involved giving the wrong type of blood or blood component to a patient.[6] This happens, for example, if hospital staff accidentally take the wrong item out of the blood bank refrigerator.[6] Less than 1% of errors resulted in an infection.[6]

By 2012, almost all NHS hospitals, trusts, and health boards had registered with SHOT and were submitting reports.[1] Participation is now mandatory.[1]

The "Better Blood Transfusion" strategy by the UK's Department of Health was based on evidence collected by SHOT.[5]

References edit

  1. ^ a b c d e Bolton-Maggs, Paula H. B.; Cohen, Hannah (1 November 2013). "Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety". British Journal of Haematology. 163 (3): 303–314. doi:10.1111/bjh.12547. ISSN 1365-2141. PMC 3935404. PMID 24032719.
  2. ^ Peters, Anna L.; van Hezel, Maike E.; Juffermans, Nicole P.; Vlaar, Alexander P. J. (January 2015). "Pathogenesis of non-antibody mediated transfusion-related acute lung injury from bench to bedside". Blood Reviews. 29 (1): 51–61. doi:10.1016/j.blre.2014.09.007. ISSN 1532-1681. PMID 25277811.
  3. ^ Müller, Marcella C. A.; van Stein, Danielle; Binnekade, Jan M.; van Rhenen, Dick J.; Vlaar, Alexander P. J. (January 2015). "Low-risk transfusion-related acute lung injury donor strategies and the impact on the onset of transfusion-related acute lung injury: a meta-analysis". Transfusion. 55 (1): 164–175. doi:10.1111/trf.12816. ISSN 1537-2995. PMID 25135630. S2CID 12891532.
  4. ^ a b Peters, Anna L.; Van Stein, Danielle; Vlaar, Alexander P. J. (September 2015). "Antibody-mediated transfusion-related acute lung injury; from discovery to prevention". British Journal of Haematology. 170 (5): 597–614. doi:10.1111/bjh.13459. ISSN 1365-2141. PMID 25921271.
  5. ^ a b c Stainsby, Dorothy; Jones, Hilary; Asher, Deborah; Atterbury, Claire; Boncinelli, Aysha; Brant, Lisa; Chapman, Catherine E.; Davison, Katy; Gerrard, Rebecca (1 October 2006). "Serious Hazards of Transfusion: A Decade of Hemovigilance in the UK". Transfusion Medicine Reviews. 20 (4): 273–282. doi:10.1016/j.tmrv.2006.05.002. PMID 17008165.
  6. ^ a b c Williamson, L M; Lowe, S; Love, E M; Cohen, H; Soldan, K; McClelland, D B L; Skacel, P; Barbara, J A J (3 July 1999). "Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports". BMJ: British Medical Journal. 319 (7201): 16–19. doi:10.1136/bmj.319.7201.16. ISSN 0959-8138. PMC 28147. PMID 10390452.

External links edit

  • Official website

April 10, 2024
serious, hazards, transfusion, shot, united, kingdom, haemovigilance, scheme, collects, analyses, anonymized, information, adverse, events, blood, transfusion, reactions, when, shot, identified, risks, related, transfusion, produces, recommendations, within, a. Serious Hazards of Transfusion SHOT is the United Kingdom s haemovigilance scheme It collects and analyses anonymized information on adverse events and blood transfusion reactions When SHOT has identified risks related to transfusion it produces recommendations within its annual reports to improve patient safety These reports are freely available on its website SHOT together with the Medicines and Healthcare products Regulatory Agency MHRA works to support haemovigilance reporting in the UK Contents 1 Results 2 History 3 References 4 External linksResults editSHOT s statistical data has been used to decrease bacterial infections through better skin cleansing procedures and the incidence of life threatening transfusion related acute lung injury TRALI in the UK by discouraging the use of fresh frozen plasma from female donors 1 The cause of TRALI is not fully understood and may have more than one mechanism 2 but most cases are associated with transfusion of plasma or other blood products that contain some antibodies that the donor developed during pregnancy 3 4 Not using plasma donation from female donors for transfusions eliminates the risk of exposing the recipient to pregnancy related antibodies and therefore reduces the risk of TRALI 4 The collected information has also provided evidence to support the pre existing practice of leukodepletion depleting the number of leukocytes or white blood cells from the product to reduce the risk of transfusion associated graft versus host disease and post transfusion purpura in immunocompromised patients 1 SHOT s data has also focused attention on human errors with the result that staff training and procedures have been improved For example SHOT s data demonstrated that increasing the use of wristbands for patient identification and portable bedside barcode readers reduced the risk of an error caused by human factors 1 History editSHOT was established in 1996 5 During the first ten years it collected more than 2 000 confidential reports about transfusion safety problems or near misses 5 During the first two years of voluntary reports about half of these errors involved giving the wrong type of blood or blood component to a patient 6 This happens for example if hospital staff accidentally take the wrong item out of the blood bank refrigerator 6 Less than 1 of errors resulted in an infection 6 By 2012 almost all NHS hospitals trusts and health boards had registered with SHOT and were submitting reports 1 Participation is now mandatory 1 The Better Blood Transfusion strategy by the UK s Department of Health was based on evidence collected by SHOT 5 References edit a b c d e Bolton Maggs Paula H B Cohen Hannah 1 November 2013 Serious Hazards of Transfusion SHOT haemovigilance and progress is improving transfusion safety British Journal of Haematology 163 3 303 314 doi 10 1111 bjh 12547 ISSN 1365 2141 PMC 3935404 PMID 24032719 Peters Anna L van Hezel Maike E Juffermans Nicole P Vlaar Alexander P J January 2015 Pathogenesis of non antibody mediated transfusion related acute lung injury from bench to bedside Blood Reviews 29 1 51 61 doi 10 1016 j blre 2014 09 007 ISSN 1532 1681 PMID 25277811 Muller Marcella C A van Stein Danielle Binnekade Jan M van Rhenen Dick J Vlaar Alexander P J January 2015 Low risk transfusion related acute lung injury donor strategies and the impact on the onset of transfusion related acute lung injury a meta analysis Transfusion 55 1 164 175 doi 10 1111 trf 12816 ISSN 1537 2995 PMID 25135630 S2CID 12891532 a b Peters Anna L Van Stein Danielle Vlaar Alexander P J September 2015 Antibody mediated transfusion related acute lung injury from discovery to prevention British Journal of Haematology 170 5 597 614 doi 10 1111 bjh 13459 ISSN 1365 2141 PMID 25921271 a b c Stainsby Dorothy Jones Hilary Asher Deborah Atterbury Claire Boncinelli Aysha Brant Lisa Chapman Catherine E Davison Katy Gerrard Rebecca 1 October 2006 Serious Hazards of Transfusion A Decade of Hemovigilance in the UK Transfusion Medicine Reviews 20 4 273 282 doi 10 1016 j tmrv 2006 05 002 PMID 17008165 a b c Williamson L M Lowe S Love E M Cohen H Soldan K McClelland D B L Skacel P Barbara J A J 3 July 1999 Serious hazards of transfusion SHOT initiative analysis of the first two annual reports BMJ British Medical Journal 319 7201 16 19 doi 10 1136 bmj 319 7201 16 ISSN 0959 8138 PMC 28147 PMID 10390452 External links editOfficial website Retrieved from https en wikipedia org w index php title Serious Hazards of Transfusion amp oldid 1205641227, wikipedia, wiki, book, books, library,

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