As with healthcare-associated infections (Chapter 10), the patient safety movement has broadened the concept of “adverse event” to include such outcomes as patient falls, delirium, pressure ulcers, and venous thromboembolism (VTE) occurring in healthcare facilities. The rationale for this inclusion is that the strategies to prevent these complications of medical care are similar to those used to prevent other errors. Such strategies include education, culture change, audit and feedback, improved teamwork, and the use of checklists and bundles.
Moreover, as a practical matter, inclusion of these complications under the broad umbrella of patient safety has increased their visibility, thus making available more resources to combat them. It has also facilitated their inclusion within policy initiatives being used to promote safety. For example, postoperative VTE is on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators list (Appendix V), and is included among the preventable adverse events that are no longer reimbursed by Medicare (Appendix VIII).1
This chapter will highlight a few key complications of healthcare and the strategies that can help prevent them. Strategies to prevent readmissions and other handoff-related adverse events are covered in Chapter 8.
Hospitalized or institutionalized patients often have conditions that place them at high risk for VTE, including inactivity, comorbid diseases that increase the risk for clotting (e.g., cancer, nephrotic syndrome, heart failure), and indwelling catheters. Moreover, because such patients often have limited cardiopulmonary reserve, a pulmonary embolism (PE) can be quite consequential, even fatal. In fact, autopsy studies have shown approximately half the patients who die in hospitals have had a PE, with most of these cases unrecognized antemortem.2
The risk of VTE in a hospitalized patient is hard to determine with certainty, because it varies widely depending on the ascertainment method. Studies relying on clinical diagnosis have found rates of 20% for deep venous thrombosis and 1% to 2% for PE after major surgical procedures in the absence of prophylaxis. Rates after certain orthopedic procedures are even higher. Studies using more aggressive observational methods (i.e., Doppler ultrasounds on every postoperative patient) have found much higher rates. It is not known how many of these asymptomatic clots would have caused clinical problems, but surely some would have.
A detailed review of strategies to prevent VTE is beyond the scope of this chapter; the interested reader is referred to a number of excellent reviews, particularly the regularly updated guidelines published by the American College of Chest Physicians (ACCP).3 Instead, in keeping with the patient safety focus on systems, our emphasis will be on creating systems that ensure that every eligible patient receives appropriate, evidence-based prophylaxis.
Given the complexity of the VTE prophylaxis decision (which varies by patient group and clinical situation, and changes rapidly with new research and pharmacologic agents), it seems unlikely that physician education, the traditional approach, is the best ...