BMJ 1999;319:16-19 ( 3 July )

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Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

L M Williamson, lecturer/consultant in transfusion medicine, ^a S Lowe, SHOT assistant national coordinator, ^b E M Love, consultant haematologist, ^b H Cohen, consultant in haematology, ^c K Soldan, infection surveillance officer, ^d D B L McClelland, director, ^e P Skacel, senior lecturer in haematology, ^f J A J Barbara, microbiology consultant to National Blood Authority. ^g

^a National Blood Service East Anglia/University of Cambridge Division of Transfusion Medicine, Cambridge CB2 2PT, ^b National Blood Service Manchester, Manchester M13 9LL, ^c University College London Hospitals, London WC1E 6DB, ^d National Blood Service, Public Health Laboratory Service Communicable Disease Surveillance Centre, Colindale, London NW9 5EQ, ^e Edinburgh and South East Scotland Blood Transfusion Service, Department of Transfusion Medicine, Royal Infirmary, Edinburgh EH3 9HB, ^f Royal Postgraduate Medical School, Hammersmith Hospital, London W12 OHS, ^g National Blood Service, Colindale, London NW9 5BG

Correspondence to: L M Williamson lorna.williamson{at}nbs.nhs.uk

Objective: To receive and collate reports of death or major complications of transfusion of blood or components.
Design: Haematologists were invited confidentially to report deaths and major complications after blood transfusion during October 1996 to September 1998.
Setting: Hospitals in United Kingdom and Ireland.
Subjects: Patients who died or experienced serious complications, as defined below, associated with transfusion of red cells, platelets, fresh frozen plasma, or cryoprecipitate.
Main outcome measures: Death, "wrong" blood transfused to patient, acute and delayed transfusion reactions, transfusion related acute lung injury, transfusion associated graft versus host disease, post-transfusion purpura, and infection transmitted by transfusion. Circumstances relating to these cases and relative frequency of complications.
Results: Over 24 months, 366 cases were reported, of which 191 (52%) were "wrong blood to patient" episodes. Analysis of these revealed multiple errors of identification, often beginning when blood was collected from the blood bank. There were 22 deaths from all causes, including three from ABO incompatibility. There were 12 infections: four bacterial (one fatal), seven viral, and one fatal case of malaria. During the second 12 months, 164/424 hospitals (39%) submitted a "nil to report" return.
Conclusions: Transfusion is now extremely safe, but vigilance is needed to ensure correct identification of blood and patient. Staff education should include awareness of ABO incompatibility and bacterial contamination as causes of life threatening reactions to blood.

Key messages Blood transfusion, while extremely safe, has several potentially fatal hazards All staff handling blood should be aware of the importance of correct identity of sample, patient, and blood bag at all stages Resources should be directed to evaluation of methods for improving identification of patients Acute fever or collapse during or after transfusion may be due to ABO incompatibility or bacterial contamination Microbiological complications of transfusion accounted for a minor component of all reports

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