Minimizing errors of omission: behavioural reenforcement of heparin to avert venous emboli: the BEHAVE study.
OBJECTIVE
To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation.


METHODS
Prospective longitudinal observational study.


METHODS
Medical-surgical intensive care unit.


METHODS
Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit.


METHODS
Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence; and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period.


RESULTS
Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p<.001).


CONCLUSIONS
After development and implementation of an evidence-based thromboprophylaxis guideline, we found significantly more patients receiving heparin thromboprophylaxis. Guideline adherence was maintained 1 yr later. Further research is needed on which are the most effective strategies to implement patient safety initiatives in the intensive care unit.
McMullin
J
J
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Cook
D
D
Griffith
L
L
McDonald
E
E
Clarke
F
F
Guyatt
G
G
Gibson
J
J
Crowther
M
M
D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D005260:Female; D006284:Health Plan Implementation; D006493:Heparin / Q000627:therapeutic use*; D006801:Humans; D007318:Inservice Training; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D009864:Ontario / Q000453:epidemiology; D010348:Patient Care Team; D017410:Practice Guidelines as Topic; D011655:Pulmonary Embolism / Q000453:epidemiology / Q000517:prevention & control*; D020246:Venous Thrombosis / Q000453:epidemiology / Q000517:prevention & control*
D000925:Anticoagulants; D006493:Heparin