First reported 13 Feb 2013•Latest report 4 Jun 2024
Definition
What this concern includes
Includes failures of assessment, prescribing, arrangement, communication, implementation, delivery or monitoring that are specifically dedicated to preventing venous thromboembolism, including the anchor's failure to obtain and clarify discharge thromboprophylaxis requirements.
Not included
Excludes generic failures to obtain, transfer or document information unless they are specifically tied to a thromboprophylaxis decision or requirement.
Excludes unrelated medication, discharge-planning or clinical-assessment failures that do not concern venous thromboembolism prevention.
Excludes thrombosis outcomes or general immobility risks without an identified thromboprophylaxis control failure.
Reports
27
Distinct published reports
Individual concerns
35
A report can raise multiple concerns
Date range
2013–2024
First to latest report issue date
Stated actions
50
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care6
National Institute for Health and Care Excellence4
East Lancashire Hospitals NHS Trust2
East London NHS Foundation Trust2
Lancashire Teaching Hospitals NHS Foundation Trust2
NHS England2
Sussex Partnership NHS Foundation Trust2
University Hospitals Sussex NHS Foundation Trust2
Worcestershire Acute Hospitals NHS Trust2
Barts Health NHS Trust1
Bradford Teaching Hospitals NHS Foundation Trust1
Brunswick Ward at Lindridge1
Doncaster Royal Infirmary1
East and North Hertfordshire Teaching NHS Trust1
Frome Care Village1
NHS trust17
Executive non-departmental public body6
Healthcare site6
Ministerial department6
Residential care home1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Manchester North
Concerns raised1
Failure to assess high-risk community patients for VTE prevention
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North London
Concerns raised1
Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Deliver education and awareness sessions on the VTE policy and publicise policy and guideline updates through orthopaedic governance and audit meetings.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Incorporate the approved VTE risk-assessment leaflet into the revised Orthopaedics Handbook.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Add a thromboprophylaxis domain to the local pre-operative checklist to prompt anaesthetists to record prophylaxis on the anaesthetic drug chart.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Discuss the revised pre-operative checklist process with the Head of Anaesthetics.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for addressing the lack of national DVT and pulmonary embolus prevention guidelines lies with the Department of Health.
Stated by Royal Free London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing local VTE guidance requires no amendment because it is consistent with national guidance and covers major elbow surgery.
Stated by Royal Free London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester City
Concerns raised1
Delays in prescribing prophylactic anticoagulation for patients at high risk of VTE
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire (Western)
Concerns raised1
Failure to ensure discharge information addresses thromboembolism risk after trauma-related surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review patient information provided after blood-clot risk assessment.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 March 2019.
Action
Develop a revised leaflet for patients following blood-clot risk assessment.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 March 2019.
Action
Introduce the revised leaflet for all patients from 1 December 2018.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 March 2019.
Manchester South
Concerns raised1
Lack of guidance for extending clexane prophylaxis when patient mobility remains reduced
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NICE concluded that its VTE guidelines are appropriate and require no amendment at this time.
Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.
Oxfordshire
Concerns raised2
Failure to ensure staff act upon VTE prophylaxis alerts
Failure to ensure VTE prophylaxis for trauma patients outlying on non-trauma wards
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Action
Require doctors to address the VTE alert before exiting or navigating away from the electronic patient record.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2018.
Action
Audit the effectiveness of the mandatory VTE electronic patient record alert system.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2018.
Action
Streamline electronic alerts by moving soft alerts into the record sidebar and limiting hard pop-ups to key safety issues.
Stated by Oxford University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2018.
Action
Develop and deploy an electronic whiteboard displaying outstanding patient tasks and VTE prophylaxis status using traffic-light indicators.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2018.
Action
Expand personal electronic worklists to individual doctors and introduce nursing worklists for outstanding VTE prophylaxis tasks.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2018.
Action
Audit trauma patients across the Trust to benchmark VTE prophylaxis care and identify discrepancies.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2018.
Action
Review outlying trauma patients daily to verify that appropriate VTE prophylaxis is prescribed, using senior trauma nursing cover when required.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2018.
Action
Check daily at multidisciplinary meetings that reviews of outlying trauma patients are taking place.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2018.
Action
Continue consultant checks that VTE assessments and prescriptions are completed for all new trauma patients, regardless of location.
Stated by Oxford University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2018.
Action
Undertake the deferred follow-up audit of outlying trauma patients and publish its results to assess equality of VTE prophylaxis care.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The follow-up audit was deferred because variable outlier numbers required a sufficient patient sample to produce a meaningful assessment.
Stated by Oxford University Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
South Yorkshire (Eastern)
Concerns raised1
Delays in providing thromboprophylaxis exceeding 24 hours
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Reinforce the importance of prescribing VTE prophylaxis promptly.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
Action
Undertake a medical assessment unit quality-improvement project to improve completion and review of VTE assessments and timely prophylaxis prescribing and administration.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
Action
Re-launch the Stop the Clot campaign through ward and education-centre posters, internal communications, and intranet messaging about VTE assessment and prophylaxis.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
Black Country
Concerns raised1
Failure to arrange thromboprophylaxis
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Delays in completing thromboprophylaxis assessment
This report raised 25 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Blackburn, Hyndburn and Ribble Valley
Concerns raised3
Failure to re-assess venous thromboembolism risk 24 hours after admission
Failure to prescribe pharmacological thromboprophylaxis for patients at high risk of venous thromboembolism without contraindications
Failure to apply mechanical thromboprophylaxis when indicated
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of assessment, prescribing, arrangement, communication, implementation, delivery or monitoring that are specifically dedicated to preventing venous thromboembolism, including the anchor's failure to obtain and clarify discharge thromboprophylaxis requirements.
