Annual SHOT Report
The SHOT Annual Report 2020 contains bookmarks for each chapter, and links to individual chapters on the Contents pages. These enable you to easily navigate to the chapter you require.
The electronic pdf below contains the web only MHRA chapter. This does not appear in the printed version.
Chapter 18 amendment – Since release of the 2020 Annual SHOT Report, it has been brought to our attention that the antibodies found during investigation for TRALI for case 18c.5 had been submitted incorrectly. The case, based on the available information at that time, had been categorised as TAD-C (Imputability- possible) but should be categorised as ‘Equivocal TRALI’. Please see the supplementary information on TRALI chapter 18a for further details*
Please cite this document as:
S Narayan (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2020 Annual
SHOT Report (2021). https://www.shotuk.org/reports/annual-report-2020/
Annual SHOT Report Foldable Summaries
SHOT Report Foldable Summary 2020
The foldable summaries are now available to order on the following website under stock code blc789-1
NHS LeafletsAnnual SHOT Report Individual Chapters
The Annual SHOT Report 2020 is available as individual chapters by clicking below:
Chapter 2 Participation in United Kingdom (UK) Haemovigilance
Chapter 3 Headline Data – Deaths, Major Morbidity and ABO-incompatible transfusions 2020
Chapter 4 Key Messages and Recommendations 2020
Chapter 5 COVID-19 and Haemovigilance
Chapter 6 Acknowledging Continuing Excellence (ACE)
Chapter 7 Donor Haemovigilance
ERROR REPORTS
Chapter 8 Human Factors in SHOT reported errors
Chapter 9 Adverse Events Related to Anti-D Immunoglobulin
Chapter 10 Incorrect Blood Components Transfused
Chapter 11 Handling and Storage Errors
Chapter 12 Avoidable, Delayed or Under-Overtransfusion (ADU)
ERROR REPORTS WITH NO HARM
Chapter 13 Near Miss (NM) Reporting
Chapter 14 Right Blood Right Patient (RBRP)
ERROR REPORTS COMPOSITE CHAPTERS
Chapter 16 Errors Related to Information Technology (IT)
REACTIONS IN PATIENTS
Chapter 17 Febrile, Allergic and Hypotensive Reactions (FAHR)
Chapter 18 Pulmonary Complications
Chapter 19 Haemolytic Transfusion Reactions (HTR)
Chapter 20 Unusual Complications of Transfusion (UCT)
Chapter 21 Transfusion Transmitted Infections (TTI)
SPECIAL CLINICAL GROUPS
Chapter 24 Haemoglobin Disorders
Chapter 25 Immune Anti-D in Pregnancy
Chapter 26 MHRA Report on Blood Safety and Quality Regulations (BSQR) in 2020
Resources from the 2020 Annual SHOT Report
Use of SHOT resources:
The downloadable documents are the property of SHOT and have SHOT copyright. They must therefore NOT BE MODIFIED without permission.
Cases from the 2020 Annual SHOT Report
Figures from the 2020 Annual SHOT Report
Supplementary Information
Chapter 2 – Participation in UK Haemovigilance 2020
Chapter 3 – Headline Data Supplementary Information 2020
Chapter 6 – Acknowledging Continuing Excellence (ACE) 2020
Chapter 8 – Human Factors 2020
Chapter 10 – Incorrect Blood Component Transfused (IBCT) 2020
Chapter 12 – Avoidable Delayed or Under-overtransfusion (ADU) 2020
Chapter 13a – Near Miss – Wrong Blood in Tube (WBIT) 2020
Chapter 15 – Laboratory Errors 2020
Chapter 18a – Transfusion-Related Acute Lung Injury (TRALI) 2020
Chapter 20 – Uncommon Complications of Transfusion (UCT) 2020
Chapter 21 – Transfusion-Transmitted Infections (TTI) 2020
Chapter 25 – Immune Anti-D in Pregnancy 2020
2020 SHOT Recommendations Gap Analysis Tool
For the 2020 Annual SHOT Report, the SHOT Team have created a Gap Analysis Tool. This is designed to help SHOT reporting organisations to easily audit their position on SHOT Recommendations – identifying the extent to which they are already compliant, whether there are any existing gaps, and the best ways to bridge those gaps.
The template has been pre-formatted with the SHOT Recommendations. The Gap Analysis Tool includes an Action Plan, allowing organisations to record, in narrative form, comparison of current services against SHOT Recommedations, and to plan and monitor continuous improvement in patient safety.
2020 SHOT Recommendations Gap Analysis Tool