Serious Hazards of Transfusion Report
Jeremy Groves, ICS Council representative on the SHOT Steering Group, reflects on their latest report.
One of the great things about being on the ICS Council is the privilege of being able to represent the profession on various national committees. Committees aren’t every ones cup of tea of course and when at a recent Council meeting, a vacancy came up for an ICS representative on the SHOT committee, everyone suddenly seemed more interested in their computers.
I’m sure all my colleagues on Council were, like me, investigating the precise nature of the organisation. Typing shot into Google brings up the definition: ‘firing of a gun, ‘hit, stroke or kick of a ball’, ‘a photograph’. The images though are more intriguing. Lots of little glasses full of highly coloured, liquids. E-number city. A drink that even the most rational individual will down in one after an evening in the pub. Could be my sort of committee. I put my hand up.
SHOT, stands for Serious Hazards Of Transfusion and, as I’m sure you know, is the UK’s haemovigiliance scheme.
SHOT, stands for Serious Hazards Of Transfusion and, as I’m sure you know, is the UK’s haemovigiliance scheme. I attended my first meeting of the Steering Group late last year. The chair is a name familiar to the seasoned intensivist, Mark Bellamy (Prof of Intensive Care in Leeds), but the driving force is haematologist Dr Paula Bolton-Maggs who has been the medical director since 2011.
The scheme has driven many improvement in transfusion practice in the UK since it’s introduction in 1996. There is better donor selection, a greater insight into transfusion reactions, and improvements in hospital practice, particularly education and training. The result is that transfusion in the UK has never been safer. However, the main risk remains human factors. (1)
transfusion in the UK has never been safer
The report for 2016, published last year (2), has some key messages for intensivists.
- Errors continue to be responsible for most (87%) of the reports to SHOT. Many are caused by poor communication and others by distraction. I like to think the ITU team is good at the communication but the environment we work in predisposes to distraction. Not enough staff, highly stressful resuscitation situations and dealing with more than one patient at a time. The most important errors are highlighted below. Have them in your mind the next time you’re doing a cross match or have a bag of blood is in your hand.
- ABO incompatibility reactions are the tip of the SHOT iceberg. They result from a failure in sampling (wrong blood in tube) or administration of a product to the wrong patient.
- Pulmonary complications, particularly transfusion-associated circulatory overload (TAC), causes the most deaths and morbidity.
- Delayed transfusions are also a common cause of death. Delay in administration of prothrombin complex concentrate for bleeding, particularly intracranial haemorrhage is highlighted.
- Anti D immunoglobulinobulin administration. Know when to give it.
- The report encourages a better understanding of human factors to help reduce them. We are encouraged to use bedside checklists. A two-person dependent check by challenge and response process may be the safest way to do this.
- We all know that good communication, teamwork and training are essential for a well run critical care unit. The same is true for transfusion and patient safety. We also love our IT, however the report cautions that IT is not always reliable and does not replace the need for knowledge.
The report makes for interesting reading. It is rather large, but broken down into digestible chapters with helpful summaries. So, if you’ve a spare moment, why not give it a shot and when you’ve finished celebrate with another!!
- Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. B. Bolton-Maggs, H Cohen. DOI: 10.1111/bjh.12547