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The aim of the NHS Safety Thermometer is to provide a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free care’. Data is collected by Trusts on pressure ulcers, falls, urinary tract infections (UTI), and Venous Thromboembolism (VTE) assessments, prophylaxis and treatment. The North East Quality Observatory Service (NEQOS) Safety Thermometer Tool allows trusts to compare themselves against their peers (for improvement purposes) as well as to undertake internal comparisons across different service areas within the Trust. Produced quarterly, the tool uses National Safety Thermometer data published by NHS Digital and presents this by Trust across the North East & North Cumbria (NENC) area, providing comparisons between peers as well as with the national average, with breakdowns by service areas for detailed analysis.

On Nov 7 2023, NHS Resolution’s Safety and Learning team, hosted a virtual forum on learning from venous thromboembolism (VTE) claims in primary care. The purpose was to raise awareness of the cost and scale of harm, discuss the challenges and recommendations around recognition and treatment of VTE in general practice. We heard from a range of experts in the field with experience in developing and spreading best practice.

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 Healthcare Safety Investigation Branch (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. HSIB makes the following safety recommendation: It is recommended that the Intercollegiate Stroke Working Party with support from the Joint Stroke Medicine Committee and NHS England and NHS Improvement develop a stroke specific venous thromboembolism (VTE) assessment tool and system for ordering the associated treatment for patients who have suffered a stroke. HSIB recommend that the Intercollegiate Stroke Working Party supports development of a tool that ensures that important information is recorded and reviewed at appropriate intervals. The following points should be considered in the development of this tool: • The aetiology/type of stroke (ischaemic and haemorrhagic). • A record of the individual risk factors for VTE that are identified. • Contraindications for VTE treatment measures. • The VTE preventative treatment recommendation. • The record of administration of that treatment. • The reason that treatment is not administered. • Patient’s level of mobility and activity (in relation to IPC administration). • Frequency of IPC devices checking. • Record of patient’s consent and understanding of risk/benefits of intervention, including patient’s decision.

A significant fall in maternal death due to Venousthromboembolisation (VTE) followed the publication of the Royal College of Obstetricians and Gynaecologists guideline ‘Thromboprophylaxis’ in 2004. It is likely that the fall in deaths is the result of better recognition of at-risk women and widespread thromboprophylaxis. All women should undergo a documented assessment of risk factors for VTE in early pregnancy or before pregnancy. All pregnant women should have a documented VTE risk assessment at the booking appointment whilst the comprehensive history is being taken. This guideline written by Mid and South Essex Hospitals is designed to help maternity staff to identify, counsel and put the women who need antenatal and postpartum thromboprophylaxis on the correct pathway of care.

All patients should be risk assessed for venous thromboembolism (VTE) on admission to hospital. Patients should be reassessed within 24 hours of admission and whenever the clinical situation changes. This template checklist produced by the Department of Health and the National Institute for Heath and Clinical Excellence, is to aid the assessment in risk assessing patients for VTE.

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. NICE guidance, advice, quality standards and information services for health, public health and social care. Guidance also contains resources to help maximise use of evidence and guidance.  This guideline (NG89) covers assessing and reducing the risk of venous thromboembolism (VTE or blood clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help healthcare professionals identify people most at risk and describes interventions that can be used to reduce the risk of VTE.

Venous thromboembolism (VTE) is responsible for over 25,000 deaths a year in the UK, including 10% of hospital inpatient deaths. A House of Commons report in 2005 led to the development of guidance by the National Patient Safety Agency (NPSA), the National Institute for Health and Clinical Excellence (NICE) and the Chief Medical Officer, for the safe use of anticoagulants and other measures to prevent VTE (deep vein thrombosis and pulmonary embolism). VTE prevention is a patient safety priority for the National Health Service (NHS). The NICE 2010 guidance (CG92) requires that all adult hospital inpatients undergo a VTE risk assessment (RA) using a standardised national VTE RA template – upon admission, again 48 hours later, and whenever the patient’s clinical condition changes. Based on the national template, clinicians at Colchester Hospital University NHS Foundation Trust (CHUFT) pioneered an electronic VTE RA tool that enables the assessment to be completed in 30 seconds. This tool has the added benefits of calculating the risk of VTE and recommending appropriate prophylaxis using a pharmacological and/or mechanical agent. This decision support tool is web-based and is now available to any organisation across the globe. The tool and the VTE prevention programme at Colchester Hospital won the 2010 NHS Innovation Award for Patient Safety.

Thrombosis UK is a charity and a leader in: Identifying, Informing & Partnering the NHS, healthcare providers and individuals to work to improve prevention of venous thromboembolism (VTE) and the management and care of unavoidable VTE events. This short video explains how a blood clot might form, what the risks are and how they might be treated.

CareFlow Vitals is a mobile app and secure data storage system used to quickly and easily record patient’s vital statistics. This data is then instantly accessible to all relevant doctors, nurses or other specialists. Clinical staff can easily monitor patients, record observations and assessments, as well as escalate concerns. CareFlow Vitals has supported Barnsley Hospitals NHS Foundation Trust in delivering quality improvement and a patient safety culture. This short video explains how CareFlow has made improvements in recording venous thromboembolism assessments and in recording sepsis screening assessments.

Catch up on previous Maternity & Newborn Safety Investigations (MNSI) webinars and view slides from the presentations. Webinars and slide topics: Think beyond sepsis Sudden Unexplained Death in Epilepsy (SUDEP) First trimester deaths in England from venous thromboembolism associated with hyperemesis Maternal death from pulmonary embolism

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 venous thromboembolism (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.

This report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.

This Swedish study in The BMJ aimed to quantify the risk of deep vein thrombosis, pulmonary embolism and bleeding after Covid-19. The authors found that incidence rate ratios were significantly increased 70 days after covid-19 for deep vein thrombosis, 110 days for pulmonary embolism and 60 days for bleeding, when compared to the control period. The study demonstrates that Covid-19 is a risk factor for deep vein thrombosis, pulmonary embolism and bleeding. Its results could impact recommendations on diagnostic and prophylactic strategies against venous thromboembolism after Covid-19.

People with developmental disability have higher healthcare needs and lower life expectancy compared with the general population. Poor quality of care resulting from interpersonal and systemic discrimination may further entrench existing inequalities. Rocco Friebel and Laia Maynou examined the prevalence of five avoidable in-hospital patient safety incidents (adverse drug reactions, hospital-acquired infections, pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis, and postoperative sepsis) for four developmental disability groups (people with intellectual disability, chromosomal abnormalities, pervasive developmental disorders, and congenital malformation syndrome) in the NHS during the period April 2017–March 2019. The authors found that the likelihood of experiencing harm in disability groups was up to 2.7-fold higher than in patients without developmental disability. Patient safety incidents led to an excess length-of-stay in hospital of 3.6–15.4 days and an increased mortality risk of 1.4–15.0 percent. The authors show persisting quality differences in patients with developmental disability, requiring an explicit national policy focus on the needs of such patients to reduce inequalities, reach parity of care, and lower the burden on health system resources.

This mixed methods study in the BMJ Open aimed to investigate possible barriers and facilitators for venous thromboembolism (VTE) risk assessment in medical patients and evaluate the impact of local and national initiatives. The authors identified the following barriers to risk assessment: involvement of multiple staff in individual admissions interruptions lack of policy awareness time pressure complexity of tools They concluded that national financial sanctions appear effective in implementing guidance, where other local measures have failed.

This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE. Findings For healthcare staff, carrying out a robust assessment of risk factors for VTE is challenging, particularly in the complex and busy environment of antenatal clinics, the labour ward and on postnatal wards. Multiple competing demands, exacerbated by distractions and interruptions, mean healthcare professionals are constantly having to balance risk and safety for the pregnant women/pregnant people they care for and are trading off the thoroughness of assessments to improve efficiency. Midwives are asked to complete a number of risk assessments and screening tools to assess pregnant women’s/pregnant people’s risk at their first antenatal appointment (known as the booking appointment). However, the time needed to carry out these risks assessments may not be reflected in the time allocated for appointments. Risk assessments and screening tools are not all designed and presented in a consistent and logical way that would aid staff in completing the task. Assessment of VTE risk factors should take place routinely due to body changes in pregnancy and increased risk of VTE. Although assessing VTE risk is important, it is a relatively rare condition and there are a number of other competing risks that may take priority. Staff do not always involve pregnant women and pregnant people in, or discuss with them, the assessment of their risk factors for VTE. This means pregnant women and pregnant people may not be aware of the signs and symptoms of a possible VTE. The importance of knowing the signs and symptoms of VTE may not be fully understood or prioritised by pregnant women and pregnant people who may have other competing concerns and questions about their antenatal and postnatal care. National guidance recommends that assessment of VTE risk factors should be repeated when a pregnant woman/pregnant person presents with an ‘intercurrent problem’ (a new health issue which may or may not be related to the pregnancy). However, not all healthcare professionals understand the meaning of ‘intercurrent problem’ and therefore opportunities to reassess risk factors are missed. There is a mix of paper-based and electronic record keeping in antenatal and postnatal care. Electronic records systems may lack interoperability and suffer from poor connectivity which limits the ability of staff to access all the data, information, and knowledge they need at the time of assessment. Recommendations by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) for the development of a tool to make the current assessment of VTE risk factors simpler and more reproducible, have not been acted on. Safety observations It may be beneficial for organisations to consider guidance, such as the ‘principles for effectiveness and usability’ provided by the Chartered Institute of Ergonomics and Human Factors, when developing risk assessment tools. The aim being to ensure assessments are simple to use and therefore staff being more likely to do them thoroughly and avoid tick-box fatigue. It may be beneficial for organisations that make recommendations to improve the safety and care of pregnant women and pregnant people during their pregnancy and up to 6 weeks after birth, to have a process for reporting on responses to their recommendations. This would support transparency, making it easy to see what has been achieved and what remains outstanding. The aim being to enable tracking of the implementation of actions designed to improve safety and outcomes to ensure they happen. It may be beneficial if future research or funding is directed towards identifying the evidence base for the prescribing of low-molecular-weight heparin for venous thromboembolism risk in pregnancy and the first 6 weeks after birth. This will support the production of evidence-based clinical guidelines for the care and treatment of pregnant women and pregnant people at risk of VTE to ensure it is safe and effective.

Christopher Collinson was admitted to the Medical Assessment Unit at Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism. He was admitted at 1.28pm on 14 June 2021, but was not seen by a Doctor until 9.33pm. He was later prescribed a prophylactic dose of Enoxaparin, rather than the therapeutic dose which the doctor had intended to prescribe. He collapsed at 11.00pm suffering a cardiac arrest and could not be revived. He died at 2.14am on 15 June 2021. In her report, the coroner highlights two matters of concern in this case: Initial delay in seeing a doctor Mr Collinson was not seen by a Doctor until eight hours after he arrived at hospital. The reason given for this was that the department was highly pressured on this date, and although a junior doctor had assigned the case to them by "clicking", that doctor had not in fact been able to see Mr Collinson. He did not "unclick" the patient and therefore other doctors who may have had capacity were not aware that Mr Collinson had not been seen. The coroner expressed concerns that that the current system for allocating patients requires a manual check to see whether a patient has actually been seen once they have been allocated. She noted that if they are not seen, there is currently no way of other clinicians being aware of that, and therefore patients could be left for long periods of time without being assessed. Flaws in the electronic prescribing system process The doctor who saw Mr Collinson prescribed a prophylactic dose of Enoxaparin rather than the therapeutic dose which she had intended to prescribe. The reason for this was that the electronic prescribing system involves a drop-down box with confusing tables to select the medication. The doctor was under pressure due to the busy department and accepted that this was human error, having accidently selected the wrong medication. The coroner stated that the current electronic prescribing system does not require a doctor to perform a secondary check to ensure that they have selected the correct medication. She expressed concerns that it is easy to select the wrong medication, particularly when the department is busy and doctors are under pressure. She suggests that this could lead to further fatal outcomes for patients if they are given incorrect medication. This report was sent to University Hospitals Birmingham NHS Foundation Trust.

Compression stockings might be unnecessary for patients at moderate or high risk of blood clots who are undergoing planned surgery. A study called GAPS suggests that anti-clotting medicine alone is just as effective as using it in combination with compression stockings.  Researchers involved in the large randomised controlled study recommend that guidelines for preventing blood clots such as deep vein thrombosis (DVT) and pulmonary embolism (PE) should be changed. They suggest that compression stockings should no longer be standard care for most patients having planned surgery and taking anti-clotting medicine while in hospital. This could save the NHS in England around £63 million per year.