• Project was led by Royal United Hospitals Bath NHS Foundation Trust, as an extension of phase two of the Health Foundation’s Safer Clinical Systems 2014 programme.
  • Focused on the acute and elective care pathway at the Royal United Hospital in Bath.
  • Aimed to improve reliability in the patient assessment and prescribing process for medications that reduce the risk of venous thromboembolism (VTE).
  • Identified weaknesses in the existing patient risk assessment and prescribing system, and developed interventions to improve reliability to above 95%.

The Royal United Hospital project aimed to improve the process for assessing and prescribing medications to reduce the risk of venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism. The project focused on the acute and elective care pathway and built on previous work that the hospital trust had done to improve the reliability of critical medication delivery, through an earlier phase of the Safer Clinical Systems programme.

The team worked with stakeholders to map the care pathway and identify opportunities to educate patients about the importance of VTE assessment and medication, and to increase clinical engagement in this area. They used tools such as failure modes and effects analysis (FMEA) and hierarchical task analysis to identify weaknesses in the current system and the cultural factors affecting clinical engagement.

These insights enabled the team to develop, test and evaluate a range of interventions for improving the reliability and timeliness of VTE risk assessment and prescribing.