Start Date
5-15-2025 9:30 AM
End Date
5-15-2025 11:30 AM
Description
Background
- Hospitalized patients – particularly those with prior venous thromboembolism (VTE), reduced mobility, severe sepsis, and operative procedures - are at significantly elevated risk for recurrent VTE events1-4
- Although clinical evidence supports use of pharmacologic VTE prophylaxis in highrisk patients, gaps in delivery remain common (highlighted below):
- Miscommunication between managing teams
- Unclear documentation
- Lack of standardized peri-procedural protocols
- Challenges in care coordination
- Missed or delayed VTE prophylaxis represents a frequent and preventable threat to inpatient safety
- We present a near miss event involving a hospitalized patient with severe sepsis and history of pulmonary embolism within the past year, who experienced a 6-day delay in VTE prophylaxis in the peri-procedural period
Keywords
patient safety, VTE prophylaxis, quality improvement, EMR optimization
Included in
Inequality and Stratification Commons, Medicine and Health Commons, Medicine and Health Sciences Commons, Race and Ethnicity Commons
From Oversight to Insight: Enhancing VTE Prophylaxis Through System-Level Improvements
Background
- Hospitalized patients – particularly those with prior venous thromboembolism (VTE), reduced mobility, severe sepsis, and operative procedures - are at significantly elevated risk for recurrent VTE events1-4
- Although clinical evidence supports use of pharmacologic VTE prophylaxis in highrisk patients, gaps in delivery remain common (highlighted below):
- Miscommunication between managing teams
- Unclear documentation
- Lack of standardized peri-procedural protocols
- Challenges in care coordination
- Missed or delayed VTE prophylaxis represents a frequent and preventable threat to inpatient safety
- We present a near miss event involving a hospitalized patient with severe sepsis and history of pulmonary embolism within the past year, who experienced a 6-day delay in VTE prophylaxis in the peri-procedural period
Comments
Presented at the 2025 Jefferson Health Equity and Quality Improvement (HEQI) Summit.