Recommendations from the 2013
SHOT Report
For active recommendations from previous years and an update on their progress, please refer
to the SHOT website www.shotuk.org
Recommendations from the 2013 SHOT Report
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Key Recommendations 2013
Action
National Blood Transfusion
Committees, working with
Regional and Hospital
Transfusion Committees in
association with NHS
England patient safety
domain and equivalent
organisations in the
devolved countries and the
National Comparative Audit
Programme
Recommendation
Annual SHOT data consistently demonstrate errors to be the largest cause of adverse transfusion
incidents. In line with human factors and ergonomics research it may be better to redesign the
transfusion process by process mapping and audit at local and national level, to design out the
medical errors
NHS England, patient
safety domain
ABO incompatible transfusions may be fatal and are absolutely preventable. The two thirds that do
not result in harm should be included as reportable ‘never events’
Care Quality Commission
Management of blood and blood component transfusion to be included as a specific standard by the
Care Quality Commission. This should include the same subset of standards as currently apply to
medicines
Trust/Health Board Chief
Executive Officers and
Medical Directors
responsible for all clinical
staff
Trust/Health Board Chief
Executive Officers and
Medical Directors
responsible for all clinical
staff
Compliance
Don’t give two without review: Transfusion-associated circulatory overload is a significant hazard
particularly when elderly or other patients at risk (renal impairment, cardiac disease, obstetric
haemorrhage, gastro-intestinal haemorrhage) receive several units of blood without review and a
check on the Hb level
This advice is inspired by a campaign devised by NHSBT’s Patient Blood Management team
Advice for patients: Day case or outpatient transfusions: with the increased emphasis on day case
and community care, patients receiving transfusions need to be given printed advice, be advised to
report any symptoms or complications and provided with a 24-hour contact number
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Chapter Recommendations 2013
Participation
Action
Recommendation
Hospital Transfusion
Teams with support from
their Risk Managers and
Chief Executive Officers
SHOT data are both interesting and useful. Reporters should use this information to ensure their
organisation is participating fully across all types of incident reporting i.e. errors, pathological reactions,
anti-D immunoglobulin errors and near miss events. Participation data should be made available to
Transfusion Laboratory Managers
Compliance
Reporters should inform the SHOT office about all cases of RhD immunisation using the
alloimmunisation category in the SHOT online reporting system
Hospital Transfusion
Teams (HTTs)
Consultant Haematologists
with their Hospital
Transfusion Teams in
collaboration with NHSBT
in England
Reporters should continue to report immune anti-D that is detectable for the first time in the current
pregnancy using the electronic questionnaire in the reporting section on the SHOT website,
www.shotuk.org
Clinicians suspecting a case of hyperhaemolysis are encouraged to report this as early as possible via
their hospital haematologist to the National Health Service Blood and Transplant (NHSBT) red cell
immunohaematology (RCI) consultant (or consultant on call after 5pm). A designated RCI consultant
will follow up the case and inform Dr. Nay Win who will arrange subsequent case review and
forwarding of the anonymised data to SHOT
IBCT - Incorrect Blood Component Transfused
Action
Hospital Transfusion
Teams
Recommendation
Compliance
The majority of episodes resulting in an incorrect component transfusion result from multiple errors in
the multidisciplinary transfusion process. All professional staff participating in transfusion must perform
independent and careful checks. A simple 5-point aide memoire at the final step would remind staff to
check for the correct patient identifiers, and the prescription for the correct component and confirmation
of specific requirements
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Transfusion Laboratory
Action
Recommendation
Trust/Health Board Chief
Executive Officers,
Transfusion Laboratory
Managers, Hospital
Transfusion Teams
All blood transfusion laboratories should be familiar with and comply with the UK Transfusion
Laboratory Collaborative (UKTLC) standards. Accrediting and regulatory organisations have supported
this initiative, therefore compliance with these standards is strongly recommended
Compliance
ADU – Avoidable, Delayed or Undertransfusion
Action
Chair Foundation
Programme Committee,
Academy of Medical Royal
Colleges and National
Director UK Foundation
Programme Office
(UKFPO) in association
Recommendation
Compliance
The curriculum for Foundation Year training needs to be amended to include specific teaching on the
recognition and urgent management of haemorrhagic shock
with the General Medical
Council
Chief Executive Officers
and Medical Directors of
Hospitals/Trusts/Health
Boards and the Royal
College of General
Practitioners
Patients with iron or B12 deficiency should be carefully assessed and treated with haematinic
replacement therapy and only with transfusions of red cells when there are clear indications
Recommendations from the 2013 SHOT Report
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Anti-D Immunoglobulin
Action
Hospital Transfusion
Laboratories, Hospital
Transfusion Committees,
Trust/Health Board chief
executive officers (CEOs),
Royal College of Obstetrics
and Gynaecologists and
Royal College of Midwives
Recommendation
Compliance
There must be robust systems in place to identify woman eligible for anti-D Ig prophylaxis and to
communicate this information effectively to relevant care teams
Anti-D Ig must be made readily available for administration to women when they present with
potentially sensitising events, rather than putting the onus on them to return for the injection at a later
date
Good practice points relating to anti-D Ig from previous years

Current blood grouping and antibody screen results must be referred to when making decisions whether to issue or
administer anti-D Ig

FMH (Kleihauer) screening tests that suggest a TPH of >2mL, or that give equivocal results, should be referred for flow
cytometry at the earliest opportunity

If there is doubt about the RhD type, or whether detectable anti-D is immune or prophylactic, then anti-D Ig prophylaxis
should be continued until the issue is resolved

Peak levels of prophylactic anti-D following administration of 1500IU anti-D Ig will very rarely exceed 0.2IU/mL if administered
intramuscular (IM) or 0.4IU/mL if administered intravenously (IV)

It is important that regardless of any prior administration of anti-D Ig, that any anti-D detected at 28 weeks is quantified and
the results made available in the maternity notes

Anti-D Ig should be subject to the same standards of patient identification (ID) and traceability as blood components (Health
Service Circular ‘Better Blood Transfusion’ 3)

There should be laboratory oversight of stock control if it is risk-assessed that a remote stock of anti-D Ig is required in a
clinical location

A larger dose of anti-D Ig should be given following delivery of a RhD positive child when cell salvage is used: BCSH
recommend 1500iu as a standard dose

All healthcare professionals involved in the issue and administration of anti-D Ig must complete the anti-D modules in the
Learn Blood Transfusion e-learning programme www.learnbloodtransfusion.org.uk
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
Trusts/health boards must ensure that there is representation from midwives and obstetricians on hospital transfusion
committees, with the aim of jointly drawing up straightforward local protocols for the request, issue and use of anti-D Ig based
on well established national guidance

Cases of late administration, omission, or inappropriate administration of anti-D Ig must be the subject of internal follow-up
within Trusts/Health Boards via established governance mechanisms

All organisations involved in the issue and administration of anti-D Ig must ensure that their systems are robust with respect
to issue, receipt and recording, and should audit their systems with a view to increasing the safety and security of the process

Anti-D Ig prophylaxis for sensitising events should be administered in addition to anti-D Ig given for routine antenatal anti-D
prophylaxis (and vice versa)

Anti-D Ig prophylaxis for sensitising events should be given regardless of the presence of detectable residual prophylactic
anti-D or a ‘negative’ Kleihauer test
ATR - Acute Transfusion Reactions
Action
Recommendation
Hospital Transfusion
Teams (HTT)
Reporters should report cases fully, including clinical data such as temperature and blood pressure
prior to, and during, a reaction, especially if fever or hypotension is reported
HTTs, Histocompatibility
and Immunogenetics
laboratories
Patients who have experienced transfusion reactions should only be tested for platelet or granulocyte
antibodies within guidelines such as those set out in England by the National Health Service Blood and
Transplant (NHSBT) in their Histocompatibility and Immunogenetics user guide. The main indication
here would be persistence of severe reactions despite the use of platelets where the plasma has been
removed and replaced by suspension medium
HTTs, Day case wards
Outpatient departments and day case units should ensure patients have information about what to do if
they experience a transfusion reaction after leaving the unit
Compliance
ATR Recommendations still active from previous years:
Hospital Transfusion
Committees (HTC)
If a transfusion reaction is considered sufficiently severe that bacterial contamination is considered as a
possible diagnosis, clinicians must contact the Blood Service to discuss whether a recall of associated
components from the donation is necessary. This also applies when the hospital performs its own
bacterial testing of the component
Haematologists
Patients who have experienced an anaphylactic transfusion reaction should be discussed with an
Recommendations from the 2013 SHOT Report
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immunologist regarding further investigation and management
HTTs, Royal College of
General Practitioners
Transfusions should only be performed where there are facilities to recognise and treat anaphylaxis,
according to UK Resuscitation Council (UKRC) guidelines. This recommendation is also relevant for
other transfusion-related emergencies such as respiratory distress caused by transfusion-associated
circulatory overload (TACO) or transfusion-related acute lung injury (TRALI). In supplying to community
hospitals or for home transfusions, providers must ensure that staff caring for patients have the
competency and facilities to deal with this reaction. This is particularly relevant in the light of proposed
increase in treatment of patients outside the secondary care setting
HTR – Haemolytic Transfusion Reactions
Action
Recommendation
Transfusion Laboratory
Managers
A clotted sample should be requested for investigation of suspected haemolytic transfusion reaction
(HTR) to allow identification of weak complement binding antibodies, particularly anti-Jka and –Jkb
Transfusion Laboratory
Managers
Hospital transfusion laboratories should actively seek an antibody history when a sickle cell patient
requires transfusion, using the NHS Blood & Transplant (NHSBT) Sp-ICE system where available
(Specialist Services Electronic Reporting using Sunquest ICE)
Compliance
PTP – Post Transfusion Purpura
Action
Recommendation
Royal College of
Obstetricians to educate
maternity departments
about this complication;
Blood Services will provide
antibody cards for patients
with clinically relevant
platelet (HPA) and/or
neutrophil (HNA) antibodies
and these are supplied to
the consultant
Individuals who have been identified as having confirmed human platelet antigen (HPA) specific
alloantibodies should be informed about the potential risk of post-transfusion purpura (PTP) following
transfusion and, in the case of females of child bearing potential, the possibility of neonatal alloimmune
thrombocytopenia. The hospital clinician should take responsibility for informing such patients and
providing an antibody card provided by the laboratory as recommended in the Guidelines for the Blood
Transfusion Services
Compliance
Clinicians need to maintain awareness of this rare complication to facilitate prompt recognition and
treatment of PTP. Treatment with high dose intravenous immunoglobulin (IVIg) should be commenced
early when PTP is suspected. Serological confirmation is not required before treatment is started.
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haematologists whose
responsibility it is then to
inform and educate the
patient
Further information about PTP and advice on management is available in Practical Transfusion
Medicine
Recommendations still active from previous years:
Clinicians are encouraged to contact Blood Services if they suspect PTP (for advice and to arrange for
patient investigation at platelet reference laboratory as required)
TTI – Transfusion Transmitted Infection
Action
Hospital Transfusion
Teams (HTT), Clinicians
Recommendation
Compliance
Clinical staff requesting investigation of a possible transfusion-transmitted infection (TTI) by the UK
Blood Services are reminded to report as soon as practical to Serious Adverse Blood Reactions and
Events (SABRE) and SHOT. The reporter should remember to tick the SHOT box to prompt SHOT
reporting. Reporters should update their report once the outcome of the UK Blood Services
investigation is known. These should be reported even if not currently screened for by the Blood
Service
2012 TTI Recommendations still active
Retain suspected bacterially contaminated packs, even if near empty, for return to the Blood Service as the residue can be washed
out and cultured. Report a suspected bacterial transfusion transmitted infection (TTI) promptly to the Blood Service to allow recall of
any associated packs for testing. If sampling packs locally for bacterial testing, use ports rather than breaching the pack to minimise
environmental contamination of the pack. Action: Clinicians, Transfusion and Microbiology Laboratory Managers
Hospitals and Blood Centres investigating a possible viral TTI are reminded of the importance of locating any archived recipient
samples (transfusion-related or not) for testing. It is important that laboratories facilitate access to those samples (with due consent of
appropriate parties including the patient). Action: Clinicians, Transfusion Laboratory Managers, HTTs
2010 TTI Recommendations still active
Even if TTI is excluded in a case of ATR, the case should still be reported to SHOT as an ATR If necessary. Action: HTTs,
Clinicians
Clinicians investigating suspected viral TTIs should explore all possible risk exposures in parallel with the Blood Service
investigations, in order to determine the patient’s most likely source of infection. This includes checking records and testing samples
taken prior to the implicated transfusion(s) to check that the recipient was not infected prior to transfusion. Action: Clinicians, UK
Blood Services
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Cell Salvage
Action
Recommendation
Hospital Transfusion
Committees (HTC),
Hospital Transfusion
Teams (HTT)
Ensure that all cell salvage users in your institution are made aware of the complication of hypotension
in relation to the use of leucocyte depletion filters and the simple measures that need to be taken
should it occur
HTTs, Operating
department practitioners,
cell salvage operators
Ensure all cases of serious reactions are reported to SHOT via the hospital transfusion team
Cell salvage operators,
HTTs
Consider where a machine failure occurs, which is not due to operator error, these are reported to the
Medicines and Healthcare products Regulatory Agency (MHRA) under the Medical Devices reporting
scheme
Compliance
TACO – Transfusion Associated Circulatory Overload
Action
The Royal Colleges (of
Physicians, Surgeons,
Anaesthetists, Obstetricians
and Gynaecologists, and
Pathologists) in association
with the General Medical
Council and the Nursing
and Midwifery Council
Recommendation
Compliance
All clinical staff should be receive education and training on measures to avoid transfusionassociated circulatory overload (TACO) and the recognition of TACO, which should be included in
the curricula of trainee doctors, nurses and midwives.
Hospital Transfusion
Committees, Hospital
Transfusion Teams
‘Don’t give two without review’: When transfusing adult patients at increased risk of TACO, clinical
review should be undertaken after each red cell unit, and single units considered where appropriate,
irrespective of whether the individual has a low body weight.
Royal College of
Physicians, Royal College
of General Practitioners
Patients with chronic iron deficiency anaemia, particularly those who are elderly, should receive iron
replacement therapy, with the underlying cause of iron deficiency identified and treated
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The TACO recommendations from the 2012 report, detailed below, remain pertinent.

The 2012 British Committee for Standards in Haematology (BCSH) addendum to the blood administration guidelines on
measures to reduce the risk of transfusion-associated circulatory overload (TACO) [23, 25] should be followed

Transfer of patients during a transfusion episode is potentially hazardous and should be avoided wherever possible. If
unavoidable, clinical handover templates should include information on measures to reduce the risk of TACO and
appropriate monitoring in patients identified to be at risk by clinical assessment pre transfusion

Post-transfusion clinical assessment should be also be undertaken and patients monitored for evidence of TACO during the
first 24 hours after transfusion so that appropriate and timely management can be instituted

Transfusions should only take place where there are facilities and trained staff to monitor and manage adverse incidents
Action: All clinicians
Paediatrics
Action
Hospital Transfusion
Laboratories, Hospital
Transfusion Teams
Recommendation
Compliance
Laboratory information technology (IT) systems should be set up so that they are able to
automatically flag up age-related specific requirements such as the need for imported pathogeninactivated plasma for patients born on or after 1st January 1996
Haemoglobinopathies
Action
Recommendation
Hospital haematologists
and transfusion teams
Any case of suspected hyperhaemolysis should be reported (for hospitals served by NHSBT) to the
National Health Service Blood and Transplant (NHSBT) red cell immunohaematology (RCI)
consultant or consultant on call at the local Blood Centre as soon as possible to enable real-time data
collection and diagnosis
Haemoglobinopathy audit
group
A national review of shared care arrangements could be performed as part of the forthcoming
haemoglobinopathy audit
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Transplant Cases
Action
Recommendation
Compliance
Recommendation still active from previous years;
British Committee for
Standards in Haematology
Transfusion Task Force in
association with the British
Transplant Society
Guidelines should be developed that cover the procedures, particularly communication protocols,
necessary for managing female transplant patients who are of childbearing potential, where RhD
positive transplants have been given to RhD negative recipients. This should be a standard for all
transplant centres
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