Understanding transfusion safety

Human factors knowledge is helping to improve the understanding of safety in blood transfusions through an investigative tool which helps examine the cause of incidents. The Serious Hazards of Transfusion Human Factors Investigation Tool (SHOT HFIT) was introduced in the UK in 2017. It uses a scoring system to help evaluate the role of environment, organisation and government/regulatory factors in the cause of incidents. 

Since its roll-out, it has been used to boost the understanding of human factors principles and how they can help create a stronger safety culture. Human factors training events have been held and SHOT has created learning resources including videos, podcasts and downloadable guides.

In 2021, the questions used in HFIT were restructured to simplify the scoring and put greater emphasis on the system and organisational elements of the incident. A review of the project’s impact was presented at our Ergonomics & Human Factors 2022 conference in April. The authors are Nicola Swarbrick, Jennifer Davies, Emma Milser, Alison Watt, Debbi Poles and Shruthi Narayan.

It said: “Determining how an incident has taken place allows understanding of the gaps or failures within the system and identification of effective corrective and preventive measures that can be implemented to reduce risk of recurrence.

“Consideration of human factors supports a more sophisticated understanding of the factors that cause incidents, optimising human performance through better understanding of human behaviour and the factors that influence this behaviour, thus improving patient safety.”

The research can be found on our special website dedicated to papers from our past conferences. You can search for and browse articles dating back to 2016 and discover papers covering a wide range of sectors and topics.

Go to the site and see the paper