Root cause analysis

The National VTE Prevention Programme in England incorporates standardised guidance on risk assessment and thromboprophylaxis with a requirement for root cause analysis (RCA) of all episodes of hospital-associated thrombosis (HAT), defined as any VTE event occurring whilst an inpatient or within 90 days of discharge.

Undertaking RCA of every case of HAT is a major challenge, which requires data capture, engaging stakeholders to undertake a structured analysis of why the thromboembolic event happened, and feeding learning from the event back into the Trust quality management framework. Ensuring reliable data collection is a key issue; data is often acquired from disparate sources and multiple sites, and there is no standard approach to ensuring structured and standardised data collection and interpretation.

The ability to monitor HAT, to identify the critical underlying reasons for the occurrence of the thromboembolic event and to act in a timely manner to prevent its reoccurrence, is heavily reliant in many hospitals on manual processes, paper forms and spreadsheet reports – making HAT RCA time consuming, expensive and difficult to fully understand and monitor. Furthermore, the lack of standardisation makes national data collection and interpretation difficult.

Leaders of the VTE Exemplar Centres Network have worked with the software company MDSAS to develop an electronic tool designed to follow the flow of data capture and analysis expected when conducting RCA, by taking the user through a series of on screen prompts.

The tool, which has been piloted by King’s Thrombosis Centre, can be made available for a licence fee to all trusts who wish to use it. Please contact MDSAS directly if you wish to find out more about using the data collection tool in your own organisation.

Watch the video demonstration of the VTE RCA electronic database.

Expected outputs from the database

Recent data collection at King’s College Hospital has begun to provide insights into the nature of HAT. The King’s data gives an estimated incidence of HAT of 4.5 per 1000 admissions and HAT associated with fatal PE of 0.3 per 1000 admissions, with the most common reason for HAT related to inadequate prophylaxis.

At King’s, the analysis suggested that improved quality of risk assessment and thromboprophylaxis could reduce the annual incidence of HAT by an estimated 21 percent. The analysis points the way to future research on how to improve risk assessment and thromboprophylaxis strategies, particularly those unexpected events and those arising despite optimal TP.