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Agency for Healthcare Research Quality

Preventing Hospital-Acquired Venous Thromboembolism

A Guide for Effective Quality Improvement

Pulmonary embolism resulting from deep vein thrombosis — collectively referred to as venous thromboembolism — is the most common preventable cause of hospital death. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused. Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of one of the most important problems facing hospitalized patients, hospital-acquired venous thromboembolism.

This project was funded under grant number Grant No. 1U18 HS015826-01 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.

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Prepared by: Society of Hospital Medicine; Greg Maynard M.D., M.Sc. University of California, San Diego Medical Center; and Jason Stein, M.D., Emory University Hospitals.


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  A Preventable Problem
  How to Use This Guide
Chapter 1. Take Essential First Steps
  Ensure Support From the Institution
  Survey Previous or Ongoing Efforts and Resources
  Clarify Key Stakeholders, Reporting Hierarchy, and Approval Process
  Assemble an Effective Team
  Set General Goals and a Timeline
  Use a Structured Framework for Improvement to Plan and Guide Progress
Chapter 2. Lay Out the Evidence and Identify Best Practices
  Know What the Literature Says
  Construct the Venous Thromboembolism Protocol
  Integrate the Venous Thromboembolism Protocol
Chapter 3. Analyze Care Delivery
  Diagram Care Delivery to Identify Failure Modes
  Analyze Care Delivery to Identify "Rate-Limiting Steps"
Chapter 4. Track Performance With Metrics
  Key Metric 1: Prevalence of Appropriate Venous Thromboembolism Prophylaxis
  Key Metric 2: Incidence of Hospital-Acquired Venous Thromboembolism
  Data Collection
  Data Reporting Using Run Charts
  Transform General Goals Into a Metric-Specific Aim Statement
  Balancing Measures
Chapter 5. Layer Interventions
  The Venous Thromboembolism Protocol
  Key Principles for Effective Quality Improvement Interventions
  Beyond the Venous Thromboembolism Protocol: Using a "Hierarchy of Reliability"
Chapter 6. Continue to Improve
  Learning in the Clinical Setting: Plan-Do-Study-Act
  Spreading Improvement to Other Units

Appendix A. Talking Points to Attract Administration Support for Venous Thromboembolism Prevention Programs
Appendix B. Sample Venous Thromboembolism Protocol/Order Set
Appendix C. Suggested Reading for Venous Thromboembolism Protocol Development
Appendix D. Chart Audit Form 44



For manuscript review, we also are deeply indebted to Kathleen Kerr, Tina Budnitz, and the members of the Hospital Quality and Patient Safety Committee of the Society of Hospital Medicine.

Disclaimer and Copyright Information

No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report.

This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated.

Current as of August 2008

Internet Citation:

Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ Publication No. 08-0075, August 2008. Agency for Healthcare Research and Quality, Rockville, MD.


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