Systems Contributing to the Assurance of Transfusion Safety in the United Kingdom

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Abstract
In 1996, the United Kingdom launched a voluntary 'haemovigilance' system for confidential reporting of transfusion-related deaths and major adverse events. The Serious Hazards of Transfusion (SHOT) initiative provided the first comprehensive overview of transfusion safety in the UK, with 12 fatalities reported in the first year. The most important finding was that of a total of 169 reports, 47% were 'wrong blood to patient' episodes, of which 16 were ABO-incompatible. There were eight transfusion-transmitted infections, three bacterial, four viral and one malarial. A number of other initiatives exist in the UK which also have importance in contributing to transfusion safety. This article reviews these other key contributors, allowing SHOT to be placed in context.

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