Pharmacy
Contributions
Type: Publication Only
Background
In 2005 a House of Commons Health Committee in England reported an estimated 25000 avoidable deaths occur annually in the UK from hospital associated venous thromboembolism (VTE)1. There is ongoing work in England to develop up-to-date and accurate statistics about incidence and death from hospital associated VTE although this is difficult due to often clinically silent nature of VTE and a decrease in post-mortems in recent years.
Root cause analysis (RCA) is required for all confirmed cases of pulmonary embolism and deep vein thrombosis associated by patients in hospital, with an aim to reduce avoidable death, disability and chronic ill heath from VTE2.
Aims
- To implement a process for identification and management of hospital associated VTE events (HATs)
- To determine incidence of HATs and potentially preventable HATs
- To identify contributory factors for potentially preventable HATs
Methods
Support from senior Executives were essential in prioritising VTE as a patient safety quality improvement objective.
RCA tools were developed to explore the how, the what, and most importantly the why of HAT. RCA will identify contributory factors and inform an action plan developing solutions with monitoring to prevent reoccurrence. The VTE RCA team is multidisciplinary with Consultant Haematologist, Anticoagulation Pharmacist, lead clinician, clinical governance and radiology departments.
Weekly imaging reports are sent by the radiology team. Reports are screened to identify new VTE diagnosis. Patient records are reviewed to establish whether the VTE event is hospital associated. Lead clinicians are requested to complete the RCA tool to determine whether the HAT was potentially preventable. An action plan is implemented to address contributory factors.
Results
From April 2014 - January 2015, 6 potentially preventable HATs identified. Interventions to address contributory factors for HATs were:
- A ‘Preventing Harm’ group was introduced to investigate omitted doses of thromboprophylaxis, without clinical omission. An electronic report was created for ‘prescribed but not given’ medications, by ward.
- Agency nursing staff were given access to the electronic prescribing system to allow for documentation of medications given.
- VTE ward rounds introduced on medical, surgical and obstetric wards to review VTE risk assessment completion and accuracy, and whether thromboprophylaxis is appropriate. A summary report of findings/learning points is circulated to division.
- Risk assessment and guidance for patients with lower limb immobilisation was updated with appropriate management.
- Patient agreement to investigation or treatment consent form updated to include VTE as a significant, unavoidable or frequently occurring risk related to surgical procedures.
- WHO checklist updated to define if thromboprophylaxis is required and if prescribed.
- Educational support for accurate VTE risk assessments at booking appointments for antenatal women, to identify those at risk requiring antenatal thromboprophylaxis.
- Audits performed to assess whether patients receive verbal/written information on VTE prevention.
Summary
The VTE team implemented a robust and sustainable system for identifying and analysing HATs with feedback to departments. Successful interventions are embedded into clinical practice to reduce HATs. Key messages:
- Continuous VTE awareness, education and stewardship
- Robust action plans to drive and excel performance
- Real-time reporting
- Maintain VTE momentum – cause some noise about VTE prevention!
Keyword(s): Thrombosis, Venous thromboembolism
Session topic: Publication Only
Type: Publication Only
Background
In 2005 a House of Commons Health Committee in England reported an estimated 25000 avoidable deaths occur annually in the UK from hospital associated venous thromboembolism (VTE)1. There is ongoing work in England to develop up-to-date and accurate statistics about incidence and death from hospital associated VTE although this is difficult due to often clinically silent nature of VTE and a decrease in post-mortems in recent years.
Root cause analysis (RCA) is required for all confirmed cases of pulmonary embolism and deep vein thrombosis associated by patients in hospital, with an aim to reduce avoidable death, disability and chronic ill heath from VTE2.
Aims
- To implement a process for identification and management of hospital associated VTE events (HATs)
- To determine incidence of HATs and potentially preventable HATs
- To identify contributory factors for potentially preventable HATs
Methods
Support from senior Executives were essential in prioritising VTE as a patient safety quality improvement objective.
RCA tools were developed to explore the how, the what, and most importantly the why of HAT. RCA will identify contributory factors and inform an action plan developing solutions with monitoring to prevent reoccurrence. The VTE RCA team is multidisciplinary with Consultant Haematologist, Anticoagulation Pharmacist, lead clinician, clinical governance and radiology departments.
Weekly imaging reports are sent by the radiology team. Reports are screened to identify new VTE diagnosis. Patient records are reviewed to establish whether the VTE event is hospital associated. Lead clinicians are requested to complete the RCA tool to determine whether the HAT was potentially preventable. An action plan is implemented to address contributory factors.
Results
From April 2014 - January 2015, 6 potentially preventable HATs identified. Interventions to address contributory factors for HATs were:
- A ‘Preventing Harm’ group was introduced to investigate omitted doses of thromboprophylaxis, without clinical omission. An electronic report was created for ‘prescribed but not given’ medications, by ward.
- Agency nursing staff were given access to the electronic prescribing system to allow for documentation of medications given.
- VTE ward rounds introduced on medical, surgical and obstetric wards to review VTE risk assessment completion and accuracy, and whether thromboprophylaxis is appropriate. A summary report of findings/learning points is circulated to division.
- Risk assessment and guidance for patients with lower limb immobilisation was updated with appropriate management.
- Patient agreement to investigation or treatment consent form updated to include VTE as a significant, unavoidable or frequently occurring risk related to surgical procedures.
- WHO checklist updated to define if thromboprophylaxis is required and if prescribed.
- Educational support for accurate VTE risk assessments at booking appointments for antenatal women, to identify those at risk requiring antenatal thromboprophylaxis.
- Audits performed to assess whether patients receive verbal/written information on VTE prevention.
Summary
The VTE team implemented a robust and sustainable system for identifying and analysing HATs with feedback to departments. Successful interventions are embedded into clinical practice to reduce HATs. Key messages:
- Continuous VTE awareness, education and stewardship
- Robust action plans to drive and excel performance
- Real-time reporting
- Maintain VTE momentum – cause some noise about VTE prevention!
Keyword(s): Thrombosis, Venous thromboembolism
Session topic: Publication Only