BBTS Conference 2018

Mini SHOT Symposium

Mistakes, miscommunications, missteps along the journey of a blood bag: what can we learn from these?


Day: Thursday  |   Time: 08:45 - 10:15

Session Coordinators: 
Paula Bolton-Maggs


Speakers: 

What we learn from events reported at or after blood donation
Dr Shruthi Narayan, NHS Blood and Transplant

Black box thinking applied to component testing and processing
Chris Philips, NHS Blood and Transplant

Highlights of errors at transfusion including wastage
Dr Janet Birchall, Welsh Blood Service


Oral Presentations

Near miss blood product events - technology complacency or were we really that bad?
J. Davies, Royal Devon and Exeter NHS FT, Exeter

How much of the iceberg lies below the surface? Near miss lessons from SHOT related to critical transfusion steps
Paula Bolton-Maggs, SHOT and University of Manchester


Intended Audience
All delegates

Learning Objectives
Donation is very safe but may have adverse events; errors can occur in testing and processing, and recipients may have reactions or not need the transfusion at all

Brief Description
Haemovigilance is surveillance of blood from donation to transfusion and afterwards. What can we learn from donor adverse events, component testing and processing. What are the highlight events for recipients?

Session Tags
Blood Donation, Components & Safety
Improving Patient Outcomes
Quality, Regulation & Governance