SHOT Annual Report 2009 - Serious Hazards of Transfusion

Figure 2
Number of reports sent per reporting organisation, United Kingdom
160
140
Number of reporting organisations
120
100
80
60
40
20
0
1–5
6–10
11–15
16–20
21–25
26–30
31–35 36–40 41–45
46–50
51–55
56–60
66–70
102
2006
139
53
18
5
4
2
1
1
2007
140
55
17
6
5
2
2008
110
64
24
16
4
6
4
3
1
3
1
1
2009
103
73
34
19
10
6
4
2
1
1
1
1
Number of reports per reporting organisation
Types of reports made to SHOT
As with last year’s data, SHOT has also analysed the types of reports that organisations make, shown in Table 4 below.
The largest group in 2006 and 2007 were reporters who reported only errors and Near Miss incidents but not physiological
reactions (n = 117 and 116 respectively). In 2009 there has been a very marked decline in this number and there has been
a concomitant increase in the number of organisations reporting errors, Near Miss events and physiological reactions,
i.e. across all reporting categories (from 80 in 2006 to 206 in 2009). HTTs are to be congratulated on this dramatic
improvement. On the negative side, there is still a small group (9) of reporters who report only physiological reactions
along with 32 organisations that are reporting only errors and Near Miss incidents. It can only be assumed either that
there is no mechanism for reporting physiological reactions from patient care areas, or that there is a lack of awareness
among clinical and laboratory staff regarding the importance of reporting transfusion reactions. There may also be a
lack of awareness among junior laboratory staff and on-call staff who do not work regularly in transfusion. In 2008 SHOT
noted a number of organisations that reported only incidents relating to the administration of anti-D and some that
withdrew all their notification reports. Although fewer, there are still a very small number of organisations continuing
these patterns.
Table 4
Analysis of types of incidents reported to SHOT
Category 2006 2007 2008 2009
Organisations which reported anti-D incidents only 6 3 2 2
Organisations which reported physiological reactions only 12 11 8 9
Organisations which reported errors and Near Misses only 117 116 103 32
Organisations which reported errors and Near Misses and physiological reactions 80 88 121 206
Organisations which had all reports withdrawn 8 7 3 6
Total 223 225 237 255
3. Participation in Haemovigilance Reporting to SHOT
7