Performance and practice in UK hospital transfusion laboratories.

The two main sources of data for assessment of performance and practice are external quality assessment (EQA) and haemovigilance. In the UK both have their limitations, but are broadly representative of UK-wide clinical practice. Data from the Serious Hazards of Transfusion scheme (SHOT), show that approximately 30% of errors occur in the laboratory. ABO grouping errors are of particular concern, and were the cause of one death and one case of serious morbidity during 2004. Laboratory practice is changing, with an increase in the use of column agglutination technology (CAT) and automation, and a consequent increase in abbreviated testing. Transcription and transposition errors are a continual problem, particularly in manual systems and are responsible for many reports to SHOT as well as in EQA. Reagent selection and result interpretation play a major part in D typing errors seen in UK NEQAS exercises, with anti-CDE and potentiated anti-D reagents responsible for mistyping of rr cells. EQA results show some lack of understanding and knowledge with respect to antibody identification, with errors occurring due to inappropriate pattern matching, with no consideration given to masked antibodies. UK NEQAS data show that performance has improved enormously over the decades, but errors are still occurring in all parts of the process.

Serious hazards of transfusion: a decade of hemovigilance in the UK.

The Serious Hazards of Transfusion (SHOT) scheme is a UK-wide, independent, professionally led hemovigilance system focused on learning from adverse events. SHOT was established in 1996 as a confidential reporting system for significant transfusion-related events, building an evidence base to support blood safety policy decisions, clinical guidelines, clinician education, and improvements in transfusion practice. Recommendations are formulated by an independent steering group drawn from medical royal colleges and professional bodies. Ten years after its inception, SHOT has analyzed 2630 transfusion safety events, published 8 annual reports with recommendations, and presented data nationally and internationally. These recommendations have underpinned key initiatives, in particular the UK Department of Health "Better Blood Transfusion" strategy. SHOT has encouraged open reporting of adverse events and "near-misses" in a supportive, learning culture, vigilance in hospital transfusion practice, and evaluation of information technology to support this process. The importance of education and training has been emphasized. Detailed analysis of events has identified weaknesses in the transfusion chain. A collaborative initiative between SHOT, the Chief Medical Officer for England's National Blood Transfusion Committee, and the National Patient Safety Agency aims to reduce ABO-incompatible transfusions by improving bedside practice. Cumulative SHOT data have documented the decline in transfusion-related graft vs host disease after implementation of leucodepletion and have highlighted transfusion-related acute lung injury and bacterial contamination of platelets as important causes of death and morbidity. The UK blood services have developed strategies to reduce these risks. Future SHOT data will evaluate the success of these and other blood safety improvements.