2019 Annual SHOT report

The contents page has links to each chapter so you can easily navigate to the chapter you want to read

We will send foldable SHOT summaries with key highlights to hospital transfusion teams (clinical and laboratory) in August. 

  • The report was delivered by a webinar on 7 July 2020

Key recommendations 

  • Accurate patient identification is fundamental to patient safety. Organisations must review all patient identification errors and establish the causes of patient misidentification. Recognising gaps in existing processes, use of electronic systems, empowerment of patients and staff will reduce these errors. 
  • Clinical and laboratory staff should be trained in fundamentals of transfusion, human factors, cognitive biases, investigating incidents and patient safety principles. Such a holistic approach will ensure safe, high-quality, patient-centred care and help embed an organisation-wide culture of learning from patient safety incidents. 
  • All healthcare organisations should incorporate the principles of both Safety-I and Safety-II approaches to improve patient care and safety. Healthcare leaders should proactively seek signals for improvement from unsafe, suboptimal as well as excellent care. 
  • Healthcare management must recognise that safety and outcomes are multifaceted, a linear view of safety does not fully acknowledge the interdependencies of resources including their leadership, adequate staffing and knowledge. Healthcare leaders should ensure these are all in place to improve patient safety. 


A safe transfusion checklist, Anti-D aide memoire and an educational video covering paediatric haemovigilance are now included in Resources. 

Illustrated SHOT lessons to use as email signatures 

We have created illustrations to use as email signatures or for education, an example is: 


Download the email signature lessons. 

Si Carter-Graham, SHOT Clinical Incident Specialist