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Blood clots, particularly deep vein thrombosis (DVT) and pulmonary embolism (PE), together venous thromboembolism (VTE), pose a significant health threat to patients. These potentially life-threatening conditions can manifest silently and without warning, making vigilance and knowledge crucial. In this Top picks, we’ve pulled together resources, blogs and reports from the hub for patients and healthcare professionals, which focus on how to recognise venous thromboembolism and how to improve patient safety. 1. Deep vein thrombosis: understanding and managing your risk In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of DVT and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT. 2. HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. 3. Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. 4. Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism VTE is a significant cause of mortality, long-term disability and long-lasting ill-health problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. 5. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report This investigation by the HSIB explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. 6. NHS Resolution: Working to prevent avoidable venous thromboembolism VTE is an international patient safety issue and a clinical priority for the NHS. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. It is a leading and preventable cause of death in an estimated 25,000 of hospitalised patients each year. This information leaflet highlights the cost of VTE claims and what you can do in your organisation to prevent VTE. 7. Pulmonary embolism misdiagnosis – a systemic problem Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism, following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 8. Let's Talk Clots! Help reduce your risk of DVT and PE in hospital with this simple app Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of DVT and pulmonary embolism in hospital. 9. Patient Safety Spotlight Interview with Beverley Hunt, Professor of Thrombosis and Haemostasis and founder of Thrombosis UK In this interview, Beverley Hunt talks about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. 10. Risk assessment models for venous thromboembolism in medical inpatients This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict VTE in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies. 11. HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke This HSIB investigation focused on the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke. Do you have a resource or story to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been lost. Delays can impact treatment options and patient outcomes.  Dil Rathore is a Biomedical Scientist and Pathology Innovation Lead at Leeds Teaching Hospitals NHS Trust. In this interview, he tells us about a new tracking system he’s developed to reduce the number of patient tissue samples going missing.  Can you tell us more about the histopathology service you work with? Our histopathology service focuses on diagnosing diseases by examining tissue samples under a microscope. It is key in identifying conditions like cancer, infections and inflammation. Typically collected through biopsies or surgeries, samples are processed in various ways and we then assess the tissue’s cellular structure to detect abnormalities. Our findings guide clinical decisions, such as confirming cancer types, grading tumours and determining treatment options. The detailed reports produced by our service are essential in shaping patient care and are often discussed within multidisciplinary teams for comprehensive treatment planning. Are lost samples a problem? The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been misplaced or lost. Unfortunately, this ‘never event’ happens more often than is acceptable across the NHS and globally. While working in histopathology, I became interested in clinical systems, digital pathology and sample tracking systems. These systems are used by most NHS organisations, but they are prone to user error and are inherently flawed. They can only provide historical information about a sample's past, rather than its current location, which leads to uncertainty about where these precious patient samples are at any given time. Tissue blocks move constantly around the department to undergo additional processes. Dynamic movement around the department is both a necessity and also adds to the challenge of locating these samples. How does your new system work? From developing an understanding of sample tracking systems, I identified significant opportunities to enhance patient safety. Improvements were clearly necessary, but the technology to enable change still needed to be created. So, with support from the Innovation Pop-Up* I developed a new system. Our new system allows continuous, real-time tracking of the cassettes through Radio Frequency Identification (RFID) technology. Key elements It tells us the precise location of each sample and its movement through our histopathology department. Our custom tag provides the read ranges we require for the technology to work successfully in a clinical environment. Installing antennas and readers throughout the department allowed us to collect live data on the movements of our patients' samples. Our tag provides improved signal ranges, readability, and resilience of RFID technology in harsh processing conditions. How was this work resourced and developed? Thanks to seed funding provided by the Leeds Hospitals Charity, we were able to demonstrate ‘proof of concept’ with the innovation. Demonstrating the technological capabilities of the concept helped support an additional funding application to Innovate UK’s Knowledge Asset funding, which allowed us to scale the system as a minimal viable produce (MVP). Without support and funding, we wouldn’t have been able to develop the UK's first real-time histopathology sample tracking system. Were there challenges along the way? Innovating within the NHS has historically been difficult as the required infrastructure and support mechanisms have yet to be in place. Testing a new and/or unknown technology brings uncertainty and risk. Thanks to the support of Leeds Hospitals Charity, our Innovation Pop-Up team and the Pathology departments, we have begun to understand this process more robustly and agilely. This has led to the establishment of new methods for future innovation endeavours to allow more streamlined processes to test, and potentially adopt, innovations and new ideas. What’s next for this work? Although we are still testing and validating the data, we have seen some notable improvements since using the system: The RFID real-time tracking system offers never-before-seen visibility and data on our processes, ensuring samples are accounted for from collection to testing. This can reduce the risk of human error, leading to a more rapid turnaround of results and better patient outcomes. Pathologists' workflow can be streamlined as our labs can process samples and generate reports faster, thus optimising pathologist time, allowing for quicker decision-making and treatment initiation. The impact on patient care has been incredible. Diagnostic results are being delivered quickly, helping healthcare providers make prompt decisions regarding treatment plans, leading to improved patient outcomes and quicker recoveries. What advice would you give others wanting to develop innovations in the NHS? Carrying out due diligence and discovery is vital. Knowing what technology already exists and what current market offerings are available will begin to help shape innovation. Once you understand what you would like to see, explore current offerings to investigate if simple modifications could provide the solution. If this cannot be done, work in collaboration with other departments within your Trust (Scan4Safety, Clinical Engineering, etc.) to seek a solution. What’s next for this work? We will continue to collect data on the systems' performance and expand into other areas of the Trust to enhance the data. Once we have enough data, we hope to publish our findings. We are also exploring potential partnerships to help support the commercialisation of this innovation. If you are interested in RFID or RFID for Pathology Services, please contact Dil Singh Rathore ([email protected]), Pathology Technology & Innovation Lead, Leeds Teaching Hospitals NHS Trust. *a support programme at Leeds Teaching Hospitals NHS Trust for clinicians and entrepreneurs with ideas for new products and services that solve healthcare challenges. Share your insights and innovations Have you been been involved in rolling out a new way of working that has had a positive impact on patient safety? Could you share your approach and what you have learnt along the way? To find out how you can share your insights via the hub, get in touch with the editorial team at [email protected] or find out how to submit a blog here.

Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of Deep Vein Thrombosis and Pulmonary Embolism in hospital.

Did you know venous thromboembolism (VTE), is an umbrella term for deep vein thrombosis  and pulmonary embolism? VTE is a significant cause of mortality, long-term disability and long-lasting ill-health  problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. Read the guide via the link below