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ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/ktcquips98.html
October 01, 2014 - As a result, prevalence of appropriate VTE prophylaxis increased from 55 to 100 percent for surgical … prophylaxis and 100 percent for patients admitted to the hospitalist service between March and August … As a result of these interventions, appropriate VTE prophylaxis increased from 0 to 100 percent, and … The dashboard appears in green if the patient is on pharmacological prophylaxis, in yellow if the patient … is on sequential compression devices or if a contraindication is documented, and in red if VTE prophylaxis
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/guide1.html
February 01, 2016 - Relying on order sets alone will not reach desired levels of appropriate VTE prophylaxis. … The most effective improvement strategies focus on improving ordered prophylaxis, monitoring for care … materials around the subset of patients who may require extended duration prophylaxis. … Key metrics include the prevalence of appropriate VTE prophylaxis and the incidence of HA-VTE. … Even the best order set, however, will fail to achieve near-perfect appropriate prophylaxis.
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ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/mhs3/practices.html
April 01, 2020 - Status
Carbapenem-Resistant Enterobacteriaceae ( PDF , 1.4 MB)
Contact Precautions
Harms Due to Anticoagulants … Intervention
TCM: Transitional Care Model
Venous Thromboembolism ( PDF , 1.4 MB)
Postsurgical Prophylaxis
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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
December 01, 2017 - Bleeding concerns (e.g., anticoagulant use).
Blood availability.
Allergies. … Deep vein thrombosis prophylaxis.
Warmers.
Lab/radiology review. … Deep vein thrombosis (DVT) prophylaxis - 100% Yes.
Glycemic control - 40% Yes. … Anticoagulant use - 10% Yes.
Access issues - 20% Yes.
Airway risk - 20% Yes.
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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/tools/applying-cusp/or-briefing-audit.html
December 01, 2017 - blockers
Airway risk
Access issues
Bleeding concerns (e.g., anticoagulant … availability
Allergies
Glycemic control
Deep vein thrombosis prophylaxis
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing.pptx
December 01, 2017 - ’s policy is to measure specific clinical items related to the procedure, like deep vein thrombosis prophylaxis … Glycemic control
Allergies
Blood availability
Anticoagulant use
Access issues
Airway risk
Beta blockers … Some things are done universally, like deep vein thrombosis prophylaxis and allergies. … consent ABX given ABX redosing time Beta blockers Airway risk Access issues Bleeding concerns (e.g., anticoagulant … consent ABX given ABX redosing time Beta blockers Airway risk Access issues Bleeding concerns (e.g., anticoagulant
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/standalone_psi_casestudy.pdf
August 03, 2016 - improve DVT/PE prevention, including:
• Providing additional education and resources on existing prophylaxis … site;
• Assisting clinical pharmacists in daily identification of all patients not receiving chemical
prophylaxis … ; and
• Shifting chemical prophylaxis dosing to avoid missed doses due to changes in scheduled
surgical … investigation is whether the DVT was preventable (for example, whether
the patient was given the right prophylaxis
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
June 01, 2023 - Clinical practice guidelines for antimicrobial prophylaxis in surgery. … Postoperative nausea and vomiting prophylaxis:
1. Ondansetron
2. … Options include low molecular weight heparin, vitamin K antagonists, direct oral anticoagulants, or aspirin … Heparin*
Low molecular weight heparin*
Options may also include vitamin K antagonists, direct oral anticoagulants … Tip: Include VTE prophylaxis in admission order sets and have policy in place to prescribe VTE prophylaxis
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a4a_combo_psi_casestudy.pdf
July 06, 2016 - to Improve Hospital Quality and Safety
• Providing additional education and resources on existing prophylaxis … • Assisting clinical pharmacists in daily identification of all patients not receiving chemical
prophylaxis … ; and
• Shifting chemical prophylaxis dosing to avoid missed doses due to changes in scheduled
surgical … investigation is whether the DVT was preventable (for example, whether
the patient was given the right prophylaxis
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ce.effectivehealthcare.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
April 01, 2021 - Pneumocystis jirovecii pneumonia (PJP) prophylaxis patterns among patients with rheumatic diseases receiving … Using health-system-wide data to understand hepatitis B virus prophylaxis and reactivation outcomes in
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ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-d.html
April 01, 2017 - Warmer in place
|___| Risk of venous thromboembolism
- Compression boots and/or anticoagulants … Surgical procedure to be performed matches the consent
|___| Surgical site
|___| Has antibiotic prophylaxis
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-dec2013.pptx
January 01, 2013 -
Airway
risk
Access
issues
Bleeding
concerns
(e.g.,
anticoagulant … availability
Allergies
Glycemic
control
DVT
prophylaxis
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/50-multimodal-analgesia-facilitator.docx
June 01, 2023 - control, providers must be aware of the concurrent use of anticoagulation (even venous thromboembolism prophylaxis
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
February 09, 2005 - hazardous of drugs commonly prescribed today.8–13 Dosing errors
that result in excessively high or low anticoagulant … Anticoagulant-related
bleeding: clinical epidemiology, prediction, and
prevention. … Guideline-based
consultation to prevent anticoagulant-related bleeding. … Comparison of a nomogram and physician-adjusted
dosage of warfarin for prophylaxis against deep-vein … Computer-
adjusted dosage of anticoagulant therapy improves the
quality of anticoagulation.
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ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/ssi/ssiapj.html
April 01, 2018 - Administration
Y
Y
Peri-Op Proton Pump Inhibitor
Y
Y
Peri-Op VTE Prophylaxis
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ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - Table of Contents
Adverse Drug Events (ADEs): General Medication Topics
ADEs: Harms Due to Anticoagulants … Update
(Not reviewed)
Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants … Clinical Pharmacists
(Not reviewed)
Summary of Evidence
(Not reviewed)
ADEs: Harms Due to Anticoagulants … Prevention of Venous Thromboembolism
Summary of Evidence
Update
(Not reviewed)
Post-Surgical Prophylaxis
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ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
March 01, 2020 - Evidence of the effect of anticoagulant management services is moderately positive on time to therapeutic … Anticoagulants: Nomograms/Protocols for Novel Oral Anticoagulants
Protocol adherence
Mean time … Anticoagulants: Anticoagulant Care in Transitions Between Hospital and Home
Hemorrhagic events … Venous Thromboembolism: Use of aspirin for VTE prophylaxis
Deep vein thrombosis
Pulmonary embolism … other pharmacologic agents which, combined with its lower cost, makes it an appealing option for VTE prophylaxis
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/index.html
February 01, 2024 - Maynard also sits on an expert review panel for a phase 3 study on rivaroxaban for VTE prophylaxis in
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ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-slides.html
October 01, 2020 - hypothermia - operation >1 hour
Warmer in place
Risk of venous thromboembolism
Boots and/or anticoagulants … Has antibiotic prophylaxis been given within the last 60 minutes, if indicated? … Known allergies
Essential imaging
Antibiotic prophylaxis
Is it a safety step you might not … Iodine/tinted prep – Doesn't belong on a checklist
Antibiotic prophylaxis – Does belong on a checklist
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - Risk of hypothermia - operation >1 hour
Warmer in place
Risk of venous thromboembolism
Boots and/or anticoagulants … ’s name
Planned surgical procedure matches listing on the consent form
Surgical site
Has antibiotic prophylaxis … Known allergies
Essential imaging
Antibiotic prophylaxis
Is it a safety step you might not have … Iodine/tinted prep – Doesn’t belong on a checklist
Antibiotic prophylaxis – Does belong on a checklist