Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Brenda K. Zierler, PhD; Ann Wittkowsky, PharmD; Gene Peterson, MD, PhD; Jung-Ah Lee, MN; Courtney Jacobson, BA; Robb Glenny, MD; Fred Wolf, PhD; Lynne Robins, PhD; Pamela Mitchell, PhD; Seth Wolpin, PhD; Tom Payne, MD; Paul Hendrie, MD; Geunhye Han, MSN; Hyunjin Oh, MSN Abstract The current culture in health care is focused on patient safety and on delivering quality health care across the continuum of care. However, a culture of safety by itself cannot create change within an organization. Venous thromboembolism (VTE) requires coordination of care across multiple providers supported by a system that assists in the process of delivering and tracking outcomes of care. In this paper, we describe the implementation and use of safe practice interventions for patients who have been diagnosed with VTE or are at risk for VTE. In particular, we describe the use of the evidence-based, system-supported, interactive VTE Safety Toolkit—which includes diagnostic, preventive, and therapeutic algorithms—and the On-line Provider Training Module on VTE Prophylaxis, which is a mandatory Web-based VTE educational intervention for all providers. We describe how organizations and providers can use the VTE Safety Toolkit and On-line Provider Training Module on VTE Prophylaxis to identify business process that can be changed and create a mechanism to track provider and system performance and thereby improve patient safety and accountability around VTE. Introduction Venous thromboembolism (VTE) encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE is one of the most common clinical disorders among both inpatients and outpatients, and PE is the most common preventable cause of death among hospitalized patients in the United States. 1 Approximately 2.5 million cases of DVT and 600,000 cases of PE are diagnosed per year in the United States. About 30 percent to 40 percent of postoperative patients will develop some form of DVT, and VTE is associated with more than 300,000 hospitalizations annually. 2, 3, 4 Approximately two-thirds of patients with symptomatic VTE manifest DVT alone, whereas one-third of patients manifest PE. Appropriate prophylactic regimens for many different patient groups have been determined by randomized clinical trials, as has the appropriate treatment of established DVT. 5, 6 Errors from omission of prophylaxis or objective diagnostic testing, or inadequate treatment are estimated to result in significant harm to hospitalized patients. A fundamental understanding of prophylaxis, diagnosis, and treatment is necessary for providers throughout the continuum of patient care. Given the magnitude of the problem, it is not surprising that the diagnosis and management have been better defined for VTE than for other common diseases. 1