One specific "never event" I questioned was hospital acquired venous thromboembolic (VTE) disease which encompasses deep venous thrombosis (DVT) and/or pulmonary embolism (PE). I wrote "I am unaware of any DVT study in which no patients in the experimental arm developed DVTs or PEs. Patients will develop DVT or PE even with the best evidence-based care."
Along comes a brief research letter published last month in JAMA Surgery by a group from Johns Hopkins led by surgeon Elliott R. Haut.
Of 92 patients in their institution who had VTEs in a single year, 43 (47%) had received defect-free care. That is, each of those patients received all doses of risk-appropriate pharmacological prophylaxis ordered for the entire hospitalization.
To put it another way, VTEs for those 43 patients were not preventable. There would be no way to do a quality improvement project for a group of patients who received the right prophylaxis throughout their hospital stays and still got VTEs.
The Joint Commission/CMS criterion states that a hospital is in compliance with VTE prophylaxis if a patient receives one dose of an appropriate drug within 24 hours of admission. The Hopkins study showed that of the 49 patients (53%) whose care was suboptimal, 36 (73%) missed at least one dose of prophylaxis that was correctly ordered. Other studies have shown that missing even one dose of prophylaxis at any time during a hospitalization increases the risk of VTE.
So about half of VTEs are not preventable even with perfect adherence to the prophylaxis protocol, and the standard for compliance established by the JC/CMS is inadequate to judge the quality of an institution's performance for VTE prevention.
The study shows that 1) a lot of good information can be delivered in a two-page paper, 2) JC/CMS criteria for compliance with VTE prophylaxis need to be revisited, and 3) VTE should be removed from the list of "never events.”