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Study: Blood clots shouldn't be considered never events

Accreditation Insider, August 4, 2015

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Hospitals are being fined unfairly when their patients develop blood clots, even when they can show they’ve taken preventive measures to reduce complications, according to a study published in the July 29 issue of JAMA Surgery.

Unlike never events such as wrong site surgery or objects left behind after surgery, it’s unreasonable to expect hospitals to completely eliminate blood clots, said lead researcher Elliott R. Haut, MD, to HealthLeaders Media. Haut is an associate professor of surgery at the Johns Hopkins University School of Medicine.

Haut and his team reviewed case records for 128 patients treated between July 2010 and June 2011 at Johns Hopkins Hospital who had developed hospital-acquired venous thromboembolism (VTE). The researchers looked for evidence that the clots could have been prevented. Thirty-six percent (28%) had non-preventable, cancer-related upper extremity clots, which meant 92 patients (72%) with clots that were potentially preventable with medication. Researchers found that of the 92 patients, 79 were prescribed clot-preventing medications but only 43 received defect-free care.


The study found that the current VTE guidelines, which require that one dose of clot-preventing medication is given to patients on the first day of hospitalization, aren’t effective. Although it’s impossible to completely eliminating clots, better care can be provided for VTE patients, according to Haut.

Read the HealthLeaders article and the study abstract.



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