SHOT Annual Report 2009 - Serious Hazards of Transfusion

For the first time this year, SHOT is providing data on the number of reports per 10,000 components issued per RTC.
These data must be viewed as providing a benchmark against which to judge future reporting trends. As with the data
for the four UK countries, there is marked regional variation in England but most RTCs show an improvement over last
year’s reporting rate.
Figure 3
Mean number of reports per reporting organisation by Regional Transfusion Committee (RTC)
Mean number of reports per reporting organisation
16
14
12
10
8
6
4
2
Key
2007
2008
2009
0
East
Midlands
East of
England
London
North
East
North
West
South
Central
South
East
South
West
West
Midlands
Yorkshire
and
Humberside
Regional Transfusion Committee
The chart above shows the mean number of reports per reporting organisation by RTC for the last three years and shows
a very encouraging picture with improvements over the baseline year (2007) by all RTCs.
COMMENTARY
All the data presented in this section compare very favourably with the 2008 data. There are fewer non-reporting
organisations, fewer organisations sending only one report, and fewer organisations sending only certain subcategories
of reports. Overall reporting to SHOT has increased again in 2009 and it is anticipated that this trend will continue, as
more Trusts and hospitals establish effective adverse incident reporting systems locally, and as the new online SHOT
reporting website becomes familiar.
Reporters should remember that participating in haemovigilance remains a legal requirement. The MHRA’s Blood
Consultative Committee is aware that under-reporting or non-reporting may be an issue in some Trusts and hospitals,
and decisions regarding inspections will increasingly be made taking haemovigilance systems into account.
RECOMMENDATIONS
Many reporters have clearly taken note of the 2008 main recommendation about increasing awareness among all staff
involved in transfusion of reporting criteria for adverse events and reactions. Local reporting systems are improving
and reporting to SHOT is increasing. Nevertheless, it is still clear that not all serious adverse events and physiological
reactions are being reported to SHOT. It may be that in organisations with low SHOT reporting rates, incidents have
also not been reported locally and corrective actions are not being taken to improve patient care. In the 2008 report
3. Participation in Haemovigilance Reporting to SHOT
9