JPAC Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee
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Adverse Event Reporting

Since 2007, the Serious Hazards of Transfusion (SHOT) sheme, in conjunction with the UK Cell Salvage Action Group, have collected reports on incidents which occur in either intraoperative or postoperative cell salvage systems.
The following adverse events are being collected:

  • Abandoned procedures due to operator error (incorrect assembly, non Intravenous solutions, incorrect anticoagulant, collection time exceeded)
  • Abandoned procedures due to machine failure (clotted lines/reservoirs)
  • Adverse clinical events (Pulmonary Embolus, coagulopathy etc)

A table listing trigger events and categories for reporting can be found here

For further information please contact the SHOT office on 0161 423 4208, by email: SHOT@nhsbt.nhs.uk or at www.shotuk.org.