 | Author(s) | | | Stainsby D |
| Publication | | | Care of the Critically Ill |
| Reference | | | Vol. 19 (5) page 142-143 |
| Publication Date | | | October 2003 |
|  |  Relevant to nurses in haematology, highlighting the new findings of the 2003 SHOT report.
Since 1996 SHOT has collected reports of transfusion errors, infections and immunological reactions.
'SHOT received 482 reports of serious adverse events including 16 transfusion related deaths and 35 patients who suffered major morbidity'.
This short paper identifies that wrong blood errors are still the major risk factor 2001-2002 72% showed incorrect blood components were transfused. 30% were due to incorrect bedside checks.
33 cases of Transfusion Related Acute Lung Injury (TRALI) were suspected (a potentially life threatening complication) and contributed to 7 deaths and major morbidity in 18.
The paper goes on to identify issues in bacterial contamination and immunological complications.
This is a valuable over view of the SHOT report, which gives an insight into the ongoing need for reporting incidents, and near misses in transfusion related care.
Comment by: Tracey Burgoyne, Lecturer Practitioner Cancer Care, University of Central England Birmingham, 2004.
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