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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/44-sample-pathway-checklist.docx
June 01, 2023 - · Yes
· No
· N/A
VTE prophylaxis administered? … information, mechanical prophylaxis, chemoprophylaxis medications, and any other considerations for VTE … *Follow hospital protocol for diabetic patients
Abbreviations: N/A = not applicable; VTE = venous thromboembolism … First postoperative VTE chemoprophylaxis dose
Date:
Time:
· Yes
· No
Multimodal pain management … = venous thromboembolism
COMMENTS OR ISSUES (for process improvement):
AHRQ Pub.
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digital.ahrq.gov/sites/default/files/docs/transforming-guidelines-action-slides-06152023.pdf
June 15, 2023 - Electronic Health Record Agnostic Clinical Decision Support Tool:
A case study of the IMPROVE-DD Venous … Thromboembolism CDS Tool
Alex C. … Conducting a large impact analysis with a cluster randomized trial to test
CDS implementation of a venous … thromboembolism (VTE) risk CDS tool.
28 … RAM CDS Tool
IMPROVE-DD VTE CDS Workflow #1: VTE Prophylaxis Order Set
IMPROVE-DD VTE CDS Workflow
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/10-frontline-provider.pptx
June 01, 2023 - rate:
Include any other outcome measures you have data for at your institution (e.g., superficial SSI, venous … thromboembolism (VTE), catheter-associated urinary tract infection (CAUTI):
*The Gap Analysis and Goal … SSI, VTE Prevention
Processes for SSI, VTE prevention (antibiotic administration, skin preparation, sterile … technique, maintenance of normothermia, and VTE prophylaxis if not already administered)
Anesthesia … Prophylaxis
Process for patients to receive VTE prophylaxis (if not already administered)
ISCR at [
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effectivehealthcare.ahrq.gov/products/blood-clots-hip-knee-surgery/research-protocol
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - thromboembolism (VTE).2-4
• VTE is one of the leading causes of maternal mortality in the United States … Venous thromboembolism as a cause of severe maternal morbidity and mortality in the United States. … National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. … Improving Health Care Response to Maternal Venous Thromboembolism. … Venous thromboembolism during pregnancy and postpartum period. Eur J Intern Med. 2022;97:8-17.
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www.ahrq.gov/news/newsroom/case-studies/202504.html
June 01, 2025 - “Because we're a trauma center, our highest level of PSI was for venous thromboembolism (VTE), or blood … This team reviews every VTE case each month to determine that all patients received guideline-directed … prophylaxis; for example, the patient received the right drug at the right dose every day prior to the VTE … Systematic improvements made from PSI case reviews have improved compliance with daily guideline-directed VTE
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
May 20, 2012 - HHCEB Presentation
*
VTE Prevention:
An Institution-wide Initiative
University of Michigan
Caprini … VTE risk assessment
May 20, 2012
Marc Moote, PA-C
Chief Physician Assistant
University of Michigan Health … System
*
*
Key Strategies
Scope: ALL adult inpatients
Standardized VTE Protocol – Caprini model … prophylaxis included as peer review (OPPE) indicator for many services
Review of EVERY VTE event that … occurs in the health system for preventability
*
Closing the Gap…
VTE Risk Assessment embedded
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psnet.ahrq.gov/node/838175/psn-pdf
September 28, 2022 - Modes of failure in venous thromboembolism
prophylaxis. … Modes of failure in venous thromboembolism prophylaxis. … https://psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis
Hospital-acquired venous … thromboembolism (VTE) continues to be a significant source of preventable
patient harm. … issue/ash-clinical-practice-guidelines-venous-thromboembolism
https://psnet.ahrq.gov/issue/preventability-hospital-acquired-venous-thromboembolism
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - thromboembolism (VTE).2-4 VTE is one of the leading
causes of maternal mortality in the United States … Venous thromboembolism as a cause of severe maternal
morbidity and mortality in the United States. … National Partnership for Maternal Safety: Consensus
Bundle on Venous Thromboembolism. … Improving Health Care Response to Maternal Venous Thromboembolism. … Venous thromboembolism during pregnancy and postpartum
period. Eur J Intern Med. 2022;97:8-17.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - thromboembolism (VTE). 2-4 VTE is one of the leading causes of maternal mortality in the United States … Venous thromboembolism as a cause of severe maternal morbidity and mortality in the United States. … National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. … Risk of first venous thromboembolism in pregnant women in hospital: population-based cohort study from … Venous thromboembolism during pregnancy and postpartum period.
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs026196-Spyropoulos-final-report-2022.pdf
January 01, 2022 - We hypothesized that universal
EHR-integrated CDS utilizing a validated venous thromboembolism risk … For this trial, we hypothesized that universal EHR-integrated CDS utilizing a validated venous
thromboembolism … External validation
of the IMPROVE-DD risk assessment model for venous thromboembolism among inpatients … A Multicenter Clustered Randomized Trial of a Universal Electronic Health
Record-Based Venous Thromboembolism … Optimizing
IMPROVE-DD, a clinical decision support (CDS) web application (app) to assess venous thromboembolism
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psnet.ahrq.gov/node/45622/psn-pdf
December 07, 2016 - National Partnership for Maternal Safety: Consensus
Bundle on Venous Thromboembolism. … National Partnership for Maternal Safety: Consensus Bundle
on Venous Thromboembolism. … https://psnet.ahrq.gov/issue/national-partnership-maternal-safety-consensus-bundle-venous-
thromboembolism … Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. … https://psnet.ahrq.gov/issue/national-partnership-maternal-safety-consensus-bundle-venous-thromboembolism
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/blood-clots-hip-knee-surgery_executive.pdf
March 01, 2012 - As a whole, major
orthopedic surgery carries a risk for
venous thromboembolism (VTE), and
therefore … = venous thromboembolism
*Mortality is all-cause mortality. … Venous Thromboembolism (VTE): The occurrence of
either a deep vein thrombosis or pulmonary embolism. … Venous
Thromboembolism Prophylaxis in Orthopedic Surgery. … Venous Thromboembolism Prophylaxis in
Orthopedic Surgery.
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digital.ahrq.gov/ahrq-funded-projects/implementation-novel-multi-platform-evidence-based-clinical-decision-support
January 01, 2024 - thromboembolism risk assessment deployed to two of its largest tertiary hospitals. … thromboembolism among inpatients with COVID-19. … External validation of the IMPROVE-DD risk assessment model for venous thromboembolism among inpatients … Scaling evidence-based clinical decision support for serious conditions is difficult
Venous thromboembolism … Thromboembolism-D-Dimer (IMPROVE-DD) CDS application for VTE risk assessment; and 3) the Wells’ Criteria
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/carayon-summit2016.pdf
June 02, 2025 - Tools
Organization
EnvironmentTasks
Person
Health IT-supported process for
preventing and managing VTE … AHRQ Grant 1R01HS022086
Human-centered design
Analysis of cognitive and team work in VTE
diagnosis … information
Physical environment
Team interactions, roles
Primary data collection method on VTE … Klein et al., 1989)
Physicians, APP and nurses in 3 EDs
5
Developing Requirements of
CDS for VTE … Cues for VTE diagnosis
Table of cues
Comparative analysis of cues across 3 EDs
and roles
3.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/58-frontline-presentation-template.docx
June 01, 2023 - reviewed: [provide details on any other measures that were reviewed, for example, superficial SSI, VTE … SSI, VTE Prevention
Processes for SSI, VTE prevention (antibiotic administration, skin preparation, sterile … technique, maintenance of normothermia, and VTE prophylaxis if not already administered)
Anesthesia … Prophylaxis
Process for patients to receive VTE prophylaxis (if not already administered)
Slide 14 … Prophylaxis
Process for VTE prophylaxis
Discharge Planning
What is your multidisciplinary approach for
-
www.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - Read the impact story: University of Chicago Medicine
UChicago Medicine reduced venous thromboembolism … (VTE) incidence by 30% in the perioperative patient population across their institution with the use … of AHRQ’s Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement … Their experience using this tool is summarized in "UChicago Medicine Reduces Perioperative VTE With AHRQ
-
psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - The patient's nurse noticed that there were no orders for venous thromboembolism (VTE) prophylaxis, despite … the patient being at high risk for VTE. … The intern assumed that VTE prophylaxis was contraindicated, since the fellow had not ordered VTE prophylaxis … Therefore, the patient was not prescribed VTE prophylaxis. … on the ICU team was reviewing orders for the patient and realized that the patient was not receiving VTE
-
digital.ahrq.gov/national-webinars/reducing-provider-burden-through-better-health-it-design
January 01, 2023 - Identify the cognitive and team work involved in venous thromboembolism (VTE) prophylaxis and the sociotechnical … system design requirements that support collaborative VTE prophylaxis teamwork.
-
digital.ahrq.gov/2018-year-review/research-dissemination/web-conferences
January 01, 2018 - participants were equipped with knowledge and approaches to: 1) identify cognitive and teamwork aspects in VTE … Pascale Carayon’s research on health IT for venous thromboembolism (VTE) used 11 case studies and a … participatory approach to identify design considerations for health IT to support the process of VTE … categories of design considerations to be incorporated into a health IT system that supports the process of VTE