Serious Hazards of Transfusion (SHOT) has released a new safety notice focussing on the safe and timely administration of anti-D immunoglobulin (Ig) during the perinatal period. SHOT is the UK’s independent, professional-led haemovigilance scheme. Adverse events and information relating to the transfusion of blood and blood components, including anti-D Ig, are anonymously reported to SHOT by healthcare organisations. It is from these reports that SHOT identifies themes and produces recommendations.
SHOT’s safety notice 03, supported by the RCM, draws our attention to three themes relevant to midwifery practice: postnatal discharge prior to anti-D Ig administration; missed or late routine antenatal anti-D Ig prophylaxis (RAADP) without appropriate follow-up; and missed or misinterpreted cell-free fetal DNA testing (cffDNA). SHOT has also created a comprehensive gap analysis tool to support services to review their local guidelines, policies or protocols for anti-D Ig management.
Anti-D Ig errors have the potential for lifelong harm. We only have one chance to get it right, as maternal sensitisation to fetal RhD positive antibodies is irreversible and risks haemolytic disease of the fetus and newborn (HDFN) in future pregnancies. Timely anti-D Ig for prophylaxis and potentially sensitising events is therefore essential. Midwives are responsible for ensuring pathways are in place to provide women and birthing people with RhD negative blood type with informed choices about their options for prevention of HDFN through anti-D Ig prophylaxis.
In light of SHOT’s latest alert, the RCM is calling on members who provide care to women with RhD negative blood type to ensure that they are current and confident in their knowledge regarding anti-D Ig administration. Check out the RCM’s ilearn module and SHOT’s videos to support you with this. We also call upon members who develop guidelines, policies and protocols about anti-D administration and the care of women with RhD negative blood type to utilise SHOT’s excellent gap analysis tool. This should be used to identify local areas for improvement, develop robust pathways of care, and ensure effective failsafe reporting so that, when omissions in care are made, there are systems in place to support timely redress of these.
The RCM works closely with SHOT to ensure midwives are represented and considered when developing safety alerts and recommendations. We would encourage members to explore SHOT’s useful resources and we wanted to highlight to you their 2025 Annual Symposium.
