Transfusion delays are preventable. The
urgent provision of blood components and/or blood products is vital for life
threatening bleeding and severe anaemia. Deaths and serious harm related to
delayed transfusion continue to be reported to SHOT with the numbers increasing
each year. Review of delayed transfusions reported to SHOT between 2010-2020
found a total of 809 reports. In this 11-year period, transfusion delays
contributed to 54 potentially preventable deaths accounting for 25.5% of all
transfusion deaths reported to SHOT. The increase in reports of delayed
transfusion with 12 deaths in 2020 prompted this safety alert.
Serious Hazards of Transfusion (SHOT) is the professionally
led, independent haemovigilance scheme in the UK since 1996. Working
collaboratively with MHRA, SHOT collect reports of serious adverse reactions
and serious adverse events relating to transfusion of blood components and some
blood products, identify areas for improvement and provide recommendations for
safer transfusion practices.
This is the first alert we have issued from SHOT, and they are currently working towards becoming an accredited issuer of National Patient Safety Alerts.