In 2025, SHOT introduced Transfusion Safety Standards to promote safe, effective transfusions by identifying risks and implementing proactive strategies. Grounded in national guidance, regulatory standards, and insights from SHOT Reports, they support better patient outcomes, staff wellbeing, and system-wide safety—also addressing recommendations from the Infected Blood Inquiry.
This blog outlines:
- What the SHOT scheme is
- Why transfusion safety matters
- Common safety themes from SHOT reports, illustrated with real-world case studies.
- What we can learn to make transfusion safer for neonates and children.
This blog was produced for the .
What is SHOT?
SHOT, which stands for Serious Hazards of Transfusion, is the UK blood safety and haemovigilance scheme. All UK hospitals report transfusion reactions and errors including near misses to SHOT and each year, a summary report is produced. We have 29 years of data and have written a separate paediatric chapter since 2007.
- click the drop-down menu for SHOT on the RCPCH Patient Safety Portal.
SHOT enables the identification of recurring themes and emerging risks. By sharing report findings we aim to inform, influence, and drive meaningful changes where improvement is needed.
Children are overrepresented in error and reaction reports to SHOT.
Why is transfusion safety important? Lessons from the Infected Blood Inquiry
Transfusion safety has always been critical—but the publication of the has cast a stark spotlight on this area of patient care. It serves as a powerful reminder of the devastating consequences when safety systems fail, and reinforces the urgent need for vigilance, transparency, and continuous improvement. Overall, there were more than 30,000 infections and more than 3000 deaths.
To ensure the greatest possible safety, we need to avoid complacency. There is no basis for assuming that threats are all in the past: but watchfulness and learning the lessons of what happened in the infected blood disaster are critical to this.
What are common themes in error reports submitted to SHOT?
While the themes highlighted below reflect some of the most frequently reported errors to SHOT, incidents are submitted across all categories. No area of transfusion practice is immune, underscoring the need for vigilance and continuous improvement throughout the system. For a full summary see the Annual SHOT Reports which can be found via the link above.
Patient identification errors
Patient identification is critical to correct patient care. It is vital for transfusion but also for every other step in care: lost wrist bands, missing wrist bands, wrist bands on drip stands all have been involved in error reports. Neonatal areas are particularly vulnerable with names changes, multiple births and mislabeling of cord and maternal samples all reported.
Over (or under) transfusion
Prescribing and administration errors are another common error report. Blood components for neonates, infants and children should be prescribed in mL (usually up to the maximum dose in adults which is usually 1 unit). For infants and children, the volume of red cells required should be determined using the transfusion formula, however errors of calculation do occur.
Case example (2021 Annual SHOT Report): 7.5kg infant was prescribed 2 adult units of red cells (67ml/kg). This was due to the use of incorrect units for the transfusion formula: Hb measurement was in g/L and the g/dL formula was used). This resulted in a 10-fold error in volume prescribed. Fortunately, the error was noted after only 12mL/kg had been administered.
Delays in transfusion
Delays in transfusion occur and were subject to a National Patient Safety alert in 2022 following a worrying increase in both adult and paediatric transfusion delays reported to SHOT. Communication between clinical and laboratory areas was a recurring theme.
Case example (2024 Annual SHOT Report): A very sick preterm neonate required a platelet transfusion prior to tertiary centre transfer (DIC and central line required). There were no neonatal/infant specification units available on site. Due to failure to communicate the urgency of the situation between clinical and laboratory team there was a 6-hour delay in authorising an emergency alternative blood component for the neonate. This delay contributed to a delay in transfer and the neonate sadly died.
Incorrect blood component transfusion
There is added complexity for blood components for neonates and infants (<1 year) in that the UK Blood Services manufacture specialist neonatal/infant specification components which have more safety features for this particularly vulnerable group of patients. This added complexity, however, can result both in delays (as above) and incorrect selection of components.
It is also important that any specialist requirements such as the requirement for irradiated blood components are communicated to the laboratory. This is particularly an issue when patients are transferred between hospitals, for example, shared care in POSCUs (Paediatric Oncology Shared Care Units) or moving to different levels of Neonatal Intensive Care.
Case example (2024 Annual SHOT Report): Urgent red cell transfusion was requested for a bleeding neonate. The laboratory instructed the clinical team to use the “emergency paedipack” from the satellite refrigerator but an adult O negative pack was accidentally selected and transfused instead.
What can be learnt from transfusion reaction reports to SHOT?
Reaction reports allow us to pick up different patterns of reactions in children and allow surveillance of rare complications of transfusion. For example, children are overrepresented in the category called “Febrile, allergic and hypotensive reactions” (FAHR) and have a higher proportion of reactions to platelets compared to adults.
Rare complications of transfusion are reported into a category called UCT (uncommon complications of transfusion) and can be useful for collecting data on clinical features and risk factors. Examples of this include transfusion-associated necrotising enterocolitis (TANEC) and transfusion-associated hyperkalaemia.
Case example (2024 Annual SHOT Report): High potassium was found when the cardiopulmonary bypass prime was tested for a neonate. Potassium was found to be 19mmol/L in the neonatal/infant specification large volume transfusion (LVT) red cell unit. This unit was 3 days post donation and 15 hours post irradiation and therefore within specification. Subsequently the blood donor of the unit was investigated and found to have a genetic variant associated with familial pseudohyperkalaemia. Units from donors with this condition release potassium more quickly during storage and implicated donors are excluded from donating components for neonatal/infant use.
How can we make transfusion safer?
Firstly the safest transfusion is the one that is not actually given! Patient blood management or PBM for short is evidence-based transfusion practice. Some PBM measures are summarised below:
Conclusion
Improving transfusion safety in paediatrics starts with recognising the signals- every haemovigilance report is a vital clue. By learning from these events, sharing insights, and taking a proactive approach, we protect our youngest patients and build a safer future for every child who depends on blood transfusion.