Errors of Omission
Abstract & Commentary
Synopsis: Failure to prophylax appropriately for venous thromboembolism occurred in two thirds of preventable venous thromboembolism cases.
Source: Arnold DM, et al. Chest. 2001;120:1964-1971.
Arnold and colleagues undertook a retrospective chart review of all clinically significant episodes of venous thromboembolism (VTE) in their hospital over a 1-year period. Their aim was to determine how many cases of VTE occurred in patients who should have, but didn’t, receive VTE prophylaxis. Their criteria for VTE prophylaxis were taken from the American College of Chest Physicians (ACCP) Consensus Guidelines published in 1995.1 A total of 253 cases of VTE occurred in 245 patients during the 1-year period of the study. Of these, 230 were deep venous thromboses (DVT) and 48 were pulmonary emboli (PE). (Of those with PE, 25 had concomitant DVT.) Arnold et al excluded from analysis 21 cases as nonpreventable, 179 cases as spontaneous, and 9 cases in which prophylaxis was not possible. They were left with 44 preventable cases. Of these, 44 patients who had clinically significant, preventable VTE without adequate preventive measures, no prophylaxis at all was given in 21 patients. In 10 cases, preventive treatment was given, but for too short a time. In 9 patients, "inappropriate" (other than that stipulated by the ACCP guidelines) was given. Of the 44 patients with preventable VTE who were not adequately prophylaxed, the most common VTE risk factors were nonorthopedic general surgery (23 patients), immobility (13 patients), cancer (10 patients), obesity (8 patients), leg fracture (7 patients), and pneumonia (6 patients).
Comment by Barbara A. Phillips, MD, MSPH, FCCP
This is discouraging! It’s bad enough that VTE occurs in about half of the patients that we try to adequately anticoagulate.2 The current study indicates that we commit errors of omission leading to clinically significant VTE in about half of the preventable cases. It’s important to note that the patients in this report were identified in the hospital from clinically significant cases; doubtless, many others developed VTE that did not present clinically.
VTE, which ought to be preventable, is a killer. Its 3-month mortality rate is probably about 17%.3 That fact, coupled with the fact that DVT is often clinically undetectable right up until the massive fatal PE, makes prevention clearly the way to go. The ACCP has published evidence-based guidelines for the prevention of VTE every 3 years since 1986. An updated version was published last year.4 Imperfect as they are, these are probably the "gold standard" for VTE prevention and treatment. You can access the current Consensus Statement4 at the ACCP web site: www.chestnet.org. Then go to "Publications, CME and Products," and click on Consensus Statements and Clinical Practice Guidelines. This user-friendly web site gives several options for downloading this clinical practical guideline, including to your Palm device.
References
1. Clagett PG, et al. Chest. 1995;106:313S-334S.
2. Goldhaber SZ, et al. Chest. 2000;118:1680-1684.
3. Goldhaber SZ, et al. Lancet. 1999;353:1386-1389.
4. Geerts WH, et al. Chest. 2001;119:132S-175S.
Dr. Phillips, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington, KY, is Associate Editor of Internal Medicine Alert.
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