title: Death Associated with Inadequate Reassessment of Venous Thromboembolism Prophylaxis at and after Hospital Discharge.
abstract: Venous thromboembolism (VTE) prophylaxis, also known as thromboprophylaxis, reduces the risk of deep vein thrombosis, pulmonary embolism, and associated complications, including death, in high-risk patients. VTE prophylaxis is recommended for acutely ill, hospitalized medical patients at risk of thrombosis. Anticoagulants, the pharmacologic agents of choice to prevent VTE, are considered high-alert medications. By definition, therefore, anticoagulants bear a hightened risk of causing significant patient harm when they are used in error. As part of ongoing collaboration with a provincial death investigation service, ISMP Canada received a report of a fatal incident that involved continuation of VTE prophylaxis with enoxaparin for a patient discharge to a long-term care (LTC) facility from an acute care setting. The findings and recommendations from this case are charged to highlight the need to build routine reassessment of VTE prophylaxis into the process for discharging patients from the acute care setting and upon transfer to another facility or to primary care.
  
  
  CONCLUSIONS
  The incident described in this bulletin highlights the importance of continually reassessing the need for VTE prophylaxis, especially at transitions of care, such as discharge from an acute care setting. Evidence and guidelines confirm the benefits of VTE prophylaxis in certain patients during a hospital stay for an acute illness, but the balance of benefits and risks may become unfavourable once the patient is discharged. Clear documentation from the acute care facility can assist the receiving facility and health-care providers, as well as family caregivers, when determining whether thromboprophylaxis is still warranted. Until clear guidance to continue thromboprophylaxis after acute care is available, health-care organizations and practitioners across the spectrum of care are urged to share and consider the strategies presented in this bulletin to ensure the safe use of VTE prophylaxis and improved communication among health-care providers. ISMP Canada will be integrating the learning from this case in an update of the Hospital-Self-Assessment for Anticoagulant Safety. This assessment is available on a complimentary basis to all facilities across Canada after sign up at HTTPS://mssa.ismp-canada.org/hsasas/.
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects*; D002170:Canada; D017984:Enoxaparin / Q000008:administration & dosage*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008875:Middle Aged; D009732:Nursing Care / Q000592:standards*; D010360:Patient Transfer; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D054556:Venous Thromboembolism / Q000188:drug therapy*; D020246:Venous Thrombosis / Q000188:drug therapy*
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin