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- United States of America
- Venous Thrombosis and Thromboembolism
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Journal Article > Commentary
National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.
D'Alton ME, Friedman AM, Smiley RM et al. J Obstet Gynecol Neonatal Nurs. 2016;45:706-717.
Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. This expert commentary introduces a four-part strategy that focuses on standardization to help recognize and respond to VTE. The authors discuss the importance of reporting mechanisms to help health care organizations learn from events.
Journal Article > Study
Using multidisciplinary rounds to improve patient safety through venous thromboembolism prevention awareness.
Karasin B, Maund C. Jt Comm J Qual Patient Saf. 2015;41:428-431.
This study describes the use of multidisciplinary rounds to enhance venous thromboembolism prevention, an important patient safety target. Nurses reported on standardized questions during the review of each patient, analogous to a checklist, and gaps in prevention were reported back to physicians to rectify them. This approach is a team-based model to enhance inpatient safety and merits study of clinical outcomes.
Journal Article > Study
Preventability of hospital-acquired venous thromboembolism.
- Classic
Haut ER, Lau BD, Kraus PS, et al. JAMA Surg. 2015;150:912-915.
Prevention of hospital-acquired venous thromboembolism (VTE) is a strongly recommended patient safety practice. This retrospective review of hospital-acquired VTE at one tertiary care hospital found that many patients who developed VTE while hospitalized were prescribed appropriate prophylaxis but did not receive all of the prescribed doses. The authors point out that since current quality metrics measure only prescription of VTE prophylaxis and not actual administration, they may overestimate hospital performance on this safety issue. Moreover, nearly half of the patients with VTE had received prophylaxis that is currently considered optimal, an important finding since VTE is often referred to as a "preventable adverse event."
Journal Article > Study
Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma.
Haut ER, Lau BD, Kraenzlin FS, et al. Arch Surg. 2012;147:901-907.
A mandatory computerized clinical decision support tool improved deep vein thrombosis (DVT) prophylaxis rates and decreased preventable DVTs in trauma patients.
Journal Article > Study
Venous thromboembolism after trauma: a never event?
Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.
A subset of trauma patients had a relatively high risk of postoperative venous thromboembolism despite use of appropriate prophylactic measures, calling into question the "wisdom and justice" of classifying this complication as entirely preventable.
Journal Article > Commentary
Introducing the patient safety professional: why, what, who, how, and where?
Saint S, Krein SL, Manojlovich M, Kowalski CP, Zawol D, Shojania KG. J Patient Saf. 2011;7:175-180.
Discussing hospital-acquired conditions and strategies for prevention, this commentary recommends assigning a hospital-based clinician to assess safety at the individual patient level.
Journal Article > Study
Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.
Wiener RS, Schwartz LM, Woloshin S. Arch Intern Med. 2011;171:831-837.
Since the introduction of new diagnostic technologies in the late 1990s, pulmonary embolism diagnoses have increased, but mortality from pulmonary embolisms has not decreased. This combination of findings likely represents overdiagnosis—either due to false-positive diagnoses or detection (and treatment) of clinically insignificant clots.
Newspaper/Magazine Article
Driving out errors.
Weinstock M. Hosp Health Netw. 2011 Apr;85:46-49, 2.
This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one.
Newspaper/Magazine Article
As industry automates, adverse events continue to haunt caregivers.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.
Journal Article > Study
Hospital process compliance and surgical outcomes in Medicare beneficiaries.
Nicholas LH, Osborne NH, Birkmeyer JD, Dimick JB. Arch Surg. 2010;145:999-1004.
Hospitals are now required to report adherence to measures intended to prevent post-surgical complications, including surgical site infections. These measures are being publicly reported by groups including the Centers for Medicare and Medicaid Services. However, this analysis found that high levels of adherence to these accountability measures were not correlated with postoperative mortality, surgical site infection rate, or other complications, calling into question the value of public reporting of such measures.
Journal Article > Study
National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.
Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.
Patients with schizophrenia are at greater risk than the general population of experiencing preventable adverse events when hospitalized for medical or surgical conditions.
Journal Article > Study
Development of trigger tools for surveillance of adverse events in ambulatory surgery.
Kaafarani HM, Rosen AK, Nebeker JR, et al. Qual Saf Health Care. 2010;19:425-429.
Ambulatory surgery remains a relatively understudied area of patient safety. This article proposes a novel trigger tool for detecting postoperative adverse events after ambulatory surgical procedures.
Journal Article > Study
How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism?
White RH, Sadeghi B, Tancredi DJ, et al. Med Care. 2009;47:1237-1243.
Postoperative venous thromboembolism is one of several preventable conditions for which hospitals will not receive additional reimbursement from the Centers for Medicare and Medicaid Services. The AHRQ Patient Safety Indicators (PSIs) are intended for use in screening medical records to identify possible safety events. However, this study found that the PSI for postoperative venous thromboembolism lacks sufficient predictive ability to be used as the sole method for detecting cases.
Journal Article > Study
Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.
Byrnes MC, Schuerer DJ, Schallom ME, et al. Crit Care Med. 2009; 37:2775-2781.
Adoption of checklists to standardize and mitigate error-prone processes was popularized in patient safety through a compelling 2007 New Yorker article. The concept was further supported by its resounding success in preventing central-line–associated bloodstream infections. Similar efforts have emerged in surgical settings in which adoption of a specific checklist reduced morbidity and mortality. This study implemented a 14-point checklist in the intensive care unit (ICU) setting to actively engage providers in considering best practices during daily rounds and then evaluated whether the checklist affected practice patterns. While the study did not measure clinical patient outcomes, investigators did demonstrate significant improvements in deep vein thrombosis and stress ulcer prophylaxis, oral care for ventilated patients, electrolyte repletion, initiation of physical therapy, and documentation of restraint orders. The study also demonstrated a two-fold increase in transferring patients out of the ICU on telemetry compared with baseline practice. The authors advocate for use of this cost-effective method to promote best practices in ICU settings.
Journal Article > Study
Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator.
Henderson KE, Recktenwald AJ, Reichley RM, et al. Jt Comm J Qual Patient Saf. 2009;35:370-376.
This study confirmed that the AHRQ patient safety indicator (PSI) for postoperative deep venous thrombosis (DVT) is best used as a screening tool for identifying preventable DVT cases from administrative data. Use of the PSI identified nearly all true DVT cases but also identified a significant number of false positives.
Journal Article > Commentary
Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites.
Cook J, D'Amato C, Garrett G, Ruhnau-Gee B, Hyde L, Novak N. J AHIMA. 2009;80:62-64.
The authors explain reporting and coding requirements for various types of sentinel event data and describe how these affect coverage.
Book/Report
HealthGrades Sixth Annual Patient Safety in American Hospitals Study.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Journal Article > Study
Do patient safety events increase readmissions?
Friedman B, Encinosa W, Jiang HJ, Mutter R. Med Care. 2009;47:583-590.
Preventable medical errors have been linked to longer hospitalizations, excess costs, and increased mortality. This study explored the longer term effects of patient safety incidents by exploring whether adverse events, as measured by AHRQ's Patient Safety Indicators, were linked to an increased risk of hospital readmission. Patients who suffered a pulmonary embolism or an accidental puncture or laceration during hospitalization were significantly more likely to be readmitted within 1 month, and a broad array of adverse events were linked to a 3-month increased readmission risk. Two cases of preventable readmissions are discussed in this AHRQ WebM&M commentary.
Journal Article > Commentary
The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits.
Streiff MB, Haut ER. JAMA. 2009;301:1063-1065.
This commentary addresses the Centers for Medicare and Medicaid Services' classification of venous thromboembolism as a never event.
Journal Article > Study
A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.
Krimsky WS, Mroz IB, McIlwaine JK, et al. Qual Saf Health Care. 2009;18:74-80.
Evaluating the impact of quality and safety interventions is an evolving science. While some have argued for a new paradigm in the field, others have advocated for standards similar to clinical trials. This study developed a comprehensive approach and model to increase prophylaxis against venous thromboembolic disease, ventilator-associated pneumonia, and stress ulcers in a single intensive care unit. The model included adoption of tools that promoted team communication, prompts to providers to address the evidence-based measures on a daily basis, and a data wall to provide real-time feedback. The authors provide a detailed description of their efforts that achieved near 100% target goals and advocate for this approach in creating successful microsystems that benefit from their refined Plan-Do-Study-Act methodology.