Annual SHOT Report
The Annual SHOT Report 2023 contains bookmarks for each chapter, and links to individual chapters on the Contents page. Where chapters are referenced within another chapter, there are hyperlinks to access these directly. These enable you to easily navigate to the chapter you require.
The electronic pdf below includes the web only MHRA chapter. This does not appear in the printed version.
Please cite this document as:
Narayan, S. et al., 2024. The 2023 Annual SHOT Report, Manchester: Serious Hazards of Transfusion (SHOT) Steering Group.
Annual SHOT Report Foldable Summaries
The Annual SHOT Report summary is available to view by clicking either the image or the link below:
The foldable summaries are now available to order on the following website under stock code BLC789.4
NHS leafletsAnnual SHOT Report Individual Chapters
The Annual SHOT Report is available as individual chapters by clicking below:
2. Participation in United Kingdom (UK) Haemovigilance 2023 (1MB pdf)
3. Headline Data – Deaths, Major Morbidity and ABO-Incompatible Transfusions 2023 (2MB pdf)
4. Key Messages and Recommendations 2023 (2MB pdf)
5. The Infected Blood Inquiry and Haemovigilance 2023 (281kB pdf)
6. Acknowledging Continuing Excellence in Transfusion (ACE) 2023 (1MB pdf)
7. Donor Haemovigilance 2023 (925kB pdf)
ERROR REPORTS
8. Human Factors and Ergonomics in SHOT Error Incidents 2023 (1MB pdf)
9. Adverse Events Related to Anti-D Immunoglobulin (Ig) 2023 (1MB pdf)
10. Incorrect Blood Component Transfused (IBCT) 2023 (2MB pdf)
11. Handling and Storage Errors (HSE) 2023 (1MB pdf)
12. Avoidable, Delayed or Under-Overtransfusion (ADU) (3MB pdf)
- 12a. Delayed Transfusions 2023
- 12b. Avoidable Transfusions 2023
- 12c. Under or Overtransfusion 2023
- 12d. Incidents Related to Prothrombin Complex Concentrates 2023
ERROR REPORTS WITH NO HARM
13.-Near-Miss-NM-Reporting-2023 (1MB pdf)
14. Right Blood Right Patient (RBRP) 2023 (956kB pdf)
ERROR REPORTS COMPOSITE CHAPTERS
15. Laboratory Errors 2023 (2MB pdf)
16. Errors Related to Information Technology (IT) 2023 (1MB pdf)
REACTIONS IN PATIENTS
17. Febrile, Allergic and Hypotensive Reactions (FAHR) 2023 (1MB pdf)
18. Pulmonary Complications 2023 (3MB pdf)
- 18a. Transfusion-Associated Circulatory Overload (TACO) 2023
- 18b. Pulmonary Complications of Transfusion Non-TACO 2023
19.-Haemolytic-Transfusion-Reactions-HTR-2023 (2MB pdf)
20. Uncommon Complications of Transfusion (UCT) 2023 (677kB pdf)
21. Transfusion-Transmitted Infections (TTI) 2023 (973kB pdf)
22. Post-Transfusion Purpura (PTP) 2023 (467kB pdf)
SPECIAL CLINICAL GROUPS
23. Cell Salvage (CS) 2023 (887kB pdf)
24. Paediatric Cases 2023 (2MB pdf)
25. Haemoglobin Disorders 2023 (1MB pdf)
26. Transfusion Errors in Transplant Cases 2023 (1MB pdf)
27. Immune Anti-D in Pregnancy 2023 (1MB pdf)
28. Medicines and Healthcare products Regulatory Agency (MHRA) Report 2023 (879kB pdf)
Resources from the 2023 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 2023 Annual SHOT Report
Figures from the 2023 Annual SHOT Report
Supplementary Information
Additional analysis and case studies that could not be included in the main 2023 Annual SHOT Report is included below by chapter.
Chapter 2 – Participation in UK Haemovigilance 2023
Chapter 3 – Headline Data 2023 – coming soon
Chapter 6 – Acknowledging Continuing Excellence in Transfusion (ACE) 2023
Chapter 7 – Donor Haemovigilance 2023 – coming soon
Chapter 8 – Human Factors and Ergonomics in SHOT Error Incidents 2023
Chapter 10 – Incorrect Blood Component Transfused (IBCT) 2023
Chapter 12 – Avoidable, Delayed or Under-Overtransfusion (ADU) 2023
Chapter 15 – Laboratory Errors 2023
Chapter 16 – Errors Related to Information Technology (IT) 2023
Chapter 18b – Non-TACO Pulmonary Complications 2023
Chapter 20 – Uncommon Complications of Transfusion (UCT) 2023
Chapter 21 – Transfusion-Transmitted Infections (TTI) 2023
Chapter 23 – Cell Salvage (CS) 2023
Chapter 27 – Immune Anti-D in Pregnancy 2023
2023 SHOT Recommendations Gap Analysis Tool
The Gap Analysis Tool is now available for all SHOT reporting organisations to help identify gaps in local clinical and laboratory practices and systems to help implement the recommendations from the 2023 Annual SHOT Report and enhance transfusion safety.
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 recommendations, and to plan and monitor continuous improvement in patient safety. Please email [email protected] with any queries relating to this.
This tool is for internal use within hospital transfusion teams, and does not need to be submitted to SHOT when completed.