2023 Annual SHOT Report – Individual Chapters

Each chapter in the 2023 SHOT Annual Report is available below as a separate pdf file:

1. Foreword 2023
2. Participation in United Kingdom (UK) Haemovigilance 2023
3. Headline Data – Deaths, Major Morbidity and ABO-Incompatible Transfusions 2023
4. Key Messages and Recommendations 2023
5. The Infected Blood Inquiry and Haemovigilance 2023
6. Acknowledging Continuing Excellence in Transfusion (ACE) 2023
7. Donor Haemovigilance 2023

ERROR REPORTS – Human Factors

8. Human Factors and Ergonomics in SHOT Error Incidents 2023
9. Adverse Events Related to Anti-D Immunoglobulin (Ig) 2023
10. Incorrect Blood Component Transfused (IBCT) 2023
11. Handling and Storage Errors (HSE) 2023
12. Avoidable, Delayed or Under-Overtransfusion (ADU)

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

13a. Near Miss – Wrong Blood in Tube (WBIT) 2023

14. Right Blood Right Patient (RBRP) 2023

ERROR REPORTS COMPOSITE CHAPTERS

15. Laboratory Errors 2023
16. Errors Related to Information Technology (IT) 2023

REACTIONS IN PATIENTS

17. Febrile, Allergic and Hypotensive Reactions (FAHR) 2023
18. Pulmonary Complications 2023

18a. Transfusion-Associated Circulatory Overload (TACO) 2023
18b. Pulmonary Complications of Transfusion Non-TACO 2023

19. Haemolytic Transfusion Reactions (HTR) 2023
20. Uncommon Complications of Transfusion (UCT) 2023
21. Transfusion-Transmitted Infections (TTI) 2023
22. Post-Transfusion Purpura (PTP) 2023

SPECIAL CLINICAL GROUPS

23. Cell Salvage (CS) 2023
24. Paediatric Cases 2023
25. Haemoglobin Disorders 2023
26. Transfusion Errors in Transplant Cases 2023
27. Immune Anti-D in Pregnancy 2023

28. Medicines and Healthcare products Regulatory Agency (MHRA) Report 2023

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