Drug chart confusion contributes to pulmonary embolism


Crucial treatments missed in stroke aftercare could lead to fatal blood clots, says a new report from the Healthcare Safety Investigation Branch (HSIB).


HSIB examined the patient safety risks after looking at the case of a 78-year old woman who suffered a pulmonary embolism whilst recovering from a stroke in hospital.


Following her stroke, she was treated with ‘clot-busting’ drugs, known as thrombolysis, and had an initial assessment to determine whether she was at risk of venous thromboembolism (VTE). Due to her immobility, the patient’s risk of acquiring a DVT or pulmonary embolism (PE) was high. It was noted on her chart that she should be fitted with what is known as an intermittent pneumatic compression (IPC) device rather than receive anticoagulants to reduce her risk of VTE as recommended by NICE.


However, due to several factors, the device was never fitted and on day 19 of her rehabilitation in the hospital she was diagnosed with ‘pulmonary emboli with saddle embolism.’


She received treatment for the clots and eventually discharged 53 days after arriving at the Trust to continue her recovery at home.


Strokes are the fourth most common cause of death in the UK and around one in ten people die before they reach the hospital. HSIB’s report emphasised that if patients do survive then the assessment of care in wards and units is key to prevent any further risk to life.


HSIB’s investigation focused on what happens after thrombolysis treatment is given and how VTE risk is managed as patients recover. Early on, they identified issues such as a low rate of IPC’s being fitted despite their success in improving the survival rates of those who are not mobile after a stroke and their recommendation by NICE guidelines.


As the investigation progressed, they identified missed opportunities throughout the whole process of care.


There is a lack of a national, stroke-specific assessment for VTE that considers the patient’s specific circumstances or determines the level of risk the patient has of blood clots forming. Even if an assessment identifies IPC as a treatment, the case that HSIB examined reflected a wider picture of confusion over how the devices are recorded i.e. on the patient’s chart and who then is responsible for fitting.


HSIB’s findings also show that national guidelines don’t require a follow-up assessment or a check that the VTE preventative measure is in place.


As a result of the national investigation, HSIB made one recommendation to facilitate the development of a stroke-specific assessment, a system for the associated treatment to be recorded using a tool to ensure that the relevant information is documented and, importantly, reviewed.


Dr Stephen Drage, HSIB’s Director of Investigations and ICU consultant said:


“The time after a patient is admitted and treated for a stroke is incredibly precarious. It is important that any safety risks in the care process are mitigated to prevent life-threatening blood clots forming to give patients the best chance of making a full recovery.


“A number of barriers to the most effective aftercare emerged through our investigation and the safety issues impact not only all specialist units but any wards where stroke recovery takes place in the NHS. The recommendation we have made is aimed at ensuring that VTE risk is managed in a targeted way that ensures that patients are getting the right treatment at the right time.”


You can read the full report by clicking here. 



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