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Originator: SHOT - Serious Hazards of Transfusion

Issue date: 17-Jan-2022 10:30:07

This alert has been issued to:
  • Care Trusts
  • Mental Health Trusts
  • Specialists Trusts
  • Learning Disabilities Trusts
  • Mental Health & Social Care Trusts
  • Ambulance Trusts
  • Mental Health & Learning Disabilities Trusts
  • Acute Trusts
  • Community Trusts

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Clinical Commissioning Groups
  • Special Health Authorities
  • Territorial CMOs in Northern Ireland, Scotland & Wales
  • Regional Directors of Public Health
  • Director of Public Health

Action category: Action

Title: Preventing transfusion delays in bleeding and critically anaemic patients

Broadcast content:

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.

Additional information: This alert is not relevant to Primary Care

Alert reference: SHOT/2022/001

Action underway deadline: 21-Jan-2022

Action complete deadline: 15-Jul-2022


Contact our helpdesk

Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency