Surveillance of transfusion errors: putting data to use in the U.K.

The haemovigilance system in the U.K., the Serious Hazards of Transfusion (SHOT) scheme, was established in 1996 to collect reports of major adverse events associated with the transfusion of blood components. 92 % of eligible hospitals now participate in the scheme. The number of reports has increased every year due to an increase in the most frequent reported event, which is incorrect blood transfused (IBCT). Other complications of transfusion are all represented to a varying degree, but episodes of transfusion-transmitted infection are infrequent. The SHOT scheme has made many recommendations to improve the safety of transfusion, including that further research should be carried out into information technology solutions for safer transfusion, and into new strategies for reducing bacterial contamination and transfusion-related acute lung injury (TRALI).