July 22, 2015: Death Associated with Inadequate Reassessment of Venous Thromboembolism Prophylaxis at and after Hospital Discharge
Venous thromboembolism (VTE) prophylaxis is recommended for acutely ill, hospitalized medical patients at risk of thrombosis. 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 discharged to a long-term care (LTC) facility from an acute care setting. The findings and recommendations from this case are shared 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 primary care. Read more...
