Case Study 3. Actual Failure Modes from the University of California, San Diego Medical Center and Emory University Hospitals

• VTE risk assessment is not routine or standard.
• Bleeding risk assessment is not routine or standard.
• Most appropriate prophylaxis option for each level of risk is not conveniently available for provider.
• Differing opinions or lack of awareness exist for how at-risk some medical or surgical patients were.
• Differing opinions exist on what is appropriate, even among experts.
• Protocols differ among orthopedics, surgery, and medicine.
• Noncompliance with mechanical prophylaxis exists. For example, mechanical prophylaxis is on the floor, on the window sill, not in the room, or not delivered to the room when the patient is admitted at night or over a weekend.
• Unnecessary immobility occurs because of excessive sedation, unnecessary restraints, central lines, catheters, intravenous fluids, or oxygen therapy.
• VTE and bleeding risks change, but there is no routine or standard reassessment.
• Platelet monitoring is haphazard when heparin is ordered.
• Nonretrievable inferior vena cava filters are overused.
• Transfers out of intensive care units may cause VTE prophylaxis to be dropped.
• Prophylaxis is stopped at discharge even when risk continues in some patients.
• Widely different impressions are held for when it is safe to start anticoagulation peri-procedure and post-trauma.

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