M PRVENTING PE

 A

Here are the key clinical learning points from this case:

VTE Risk Assessment

• A documented history of prior VTE/DVT (2018) should automatically classify a patient as high-risk on admission VTE risk assessment tools
• Risk assessment must be completed and acted upon promptly at admission, not deferred or overlooked amid other priorities (e.g., post-surgical care)

Prescribing Anti-coagulation

• Don't assume a patient's prior "refusal" or "reluctance" without direct, documented confirmation from the patient or family — an assumption not supported by prior history led to a breakdown in care here
• If pharmacological prophylaxis (e.g., LMWH/Enoxaparin) is being withheld or delayed pending investigations (like a CT scan to rule out bleeding), this decision needs a clear plan and timeline — and mechanical prophylaxis should fill the gap, not be omitted too

Mechanical Prophylaxis as a Bridge

• Anti-embolism stockings should be applied at admission when pharmacological prophylaxis is delayed or contraindicated — this is a simple, low-risk intervention that was also missed for 48 hours here
• Relying on one form of prophylaxis being "pending" is not a reason to omit the other

Communication and Documentation

• Concerns noticed by any staff member (in this case, a doctor noticing missing stockings) should trigger immediate escalation and correction, not just a query to nursing staff
• Clear documentation of the rationale for withholding or delaying prophylaxis is essential — both for patient safety and for accountability
• Handover between shifts/staff should explicitly include VTE prophylaxis status, especially when a plan is "pending"

Systems-Level Point

• This case highlights how gaps in reassessment (e.g., after initial delay for CT) can result in prophylaxis being missed entirely rather than resumed once the reason for delay resolves
• Regular reassessment of VTE prophylaxis status throughout admission — not just at initial assessment — is critical, especially for high-risk patients

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