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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.

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.

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.

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.

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.

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.

This short video explains how CareFlow has made improvements in recording venous thromboembolism assessments and in recording sepsis screening assessments.