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PSNet: Patient Safety Network
Book/Report

Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.

Farnborough, UK; Healthcare Safety Investigation Branch. October 13, 2020

Errors of omission in routine care can result in patient harm. This report discusses factors contributing to a pulmonary embolism in a recovering stroke patient acerbated by a lack of intended but omitted venous thromboembolism or VTE preventative care. The system improvement recommendations drawn from the incident analysis include that the UK National Health Service develop a standardized approach to VTE risk assessment and broad-based training to enable a cross-section of clinicians to use VTE prevention devices as required.