September 2008 Premier Safety Share

Dear Colleague:

We hoped you enjoyed the seasonal break and we are back with our September issue covering latest developments, including the CMS change in reimbursement for hospital-acquired conditions, patients' reluctance to ask staff to wash hands, evidence for private rooms, challenges to clean rooms, and surgery outcomes and volumes may not be linked. Please share with your colleagues and let them know that every issue and story is archived back to 2001.

Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute

• Patients reluctant to remind providers to wash hands; New CDC video educates patients and staff
   
• CMS expands the list to 10 hospital-acquired conditions for reduced payment
   
• Cleaning of patient rooms, a persistent challenge, prompts innovative methods to evaluate effectiveness
   
• Root cause analyses explain why and how events occur; role in prevention unclear
   
• Bar-coding surgical sponges reduces risk of loss, researchers find
   
• Algorithm for selecting patient safety practices considers prevalence, cost, degree of complexity
   
• CABG mortality rates improve despite decreasing volume
   
• Color-coded wristbands moving toward a national standard
   
• Rationale for private rooms for patient safety explained

• CDC hand hygiene - Interactive training module, video, posters
   
• AHRQ/RWJF - New patient safety resource for nurses in text or CD-ROM
   
• IHI tool - Adverse Events Prevented Calculator supports quality business case
   
• RWJF - Toolkit to implement quality improvement program
   
• Premier Safety Institute – QI and patient education tools for VTE prevention

Patients reluctant to remind providers to wash hands; New CDC video educates patients and staff

Up to 91 percent of patients would ask clarification about something they don’t understand, but only 26 percent would ask a provider if they washed their hands while the rest would choose to avoid confrontation, according to a recent consumer survey on patient safety practices.

Researchers, Marella et al, developed and implemented a survey that included 10 patient safety practices and how likely and frequently consumers were to engage in those 10 practices. The survey focus was more on the healthcare consumer's inclination to perform specific practices rather than self-reported performance of a behavior. Results of the survey found the following wide variations, depending on the specific safety practice:

Most likely

• 73.6 – 91 percent of consumers reported they were positively inclined to ask healthcare workers for an explanation of something they did not understand, questioned unexpected procedures and unfamiliar drugs in the hospital, and would seek a second opinion regarding an important healthcare decision.
• 63.1 percent of consumers stated they called for medical test results and checked their drugs before they left the pharmacy.
• 46.3 – 48.5 percent reported they would refuse care in the hospital that had not previously been discussed and they always or often take a list of medications to their doctor appointments.
• 39.5 percent were less likely to ask a healthcare worker to confirm their identity before a procedure.

Least likely

• 25.9 percent were likely to ask whether they had washed their hands.

The authors concluded that healthcare consumers were more likely to perform behaviors that were aimed at informing themselves and less likely to perform behaviors that challenge a healthcare worker. Researchers concluded that the challenge for healthcare providers who want to engage patients in promoting safety is to not only educate patients on which practices help promote their safety but to provide them with non-confrontational ways of interacting with their providers.

One tool that addresses this reluctance to ask caregivers about handwashing is a new video developed by the CDC that demonstrates how patients can approach staff about hand hygiene in a non-confrontational manner. This free, five-minute video focuses on patient and staff attitudes, and shows how patients can comfortably ask their caregiver to wash or clean their hands before providing hands-on care if they haven't seen them do so. This patient and staff training tool is ideally suited for viewing on public healthcare broadcasting sites throughout the facility, such as lobbies or waiting rooms.

Downloads and links

• Marella, J Pt Safety, December 2007 abstract
• CDC video http://www.cdc.gov/handhygiene/Patient_Admission_Video.html
• Premier Safety Institute Hand Hygiene Web site

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CMS expands the list to 10 hospital-acquired conditions for reduced payment

When the final FY 2009 Inpatient Prospective Payment System (IPPS) rule takes effect on October 1, 2008, there will be 10 hospital-acquired conditions (HACs) that have potential for lower reimbursement rates, including an expansion of one of the original eight.

IPPS policy The IPPS rule is the result of the Deficit Reduction Act (DRA) of 2005, which required an adjustment in Medicare Diagnosis Related Group (DRG) payment for certain HACs with a component that addresses new Present on Admission (POA) coding. It also required the Secretary to identify, by October 1, 2007, at least two conditions for which hospitals under the IPPS would not receive additional payment beginning on October 1, 2008, if the condition was not POA. The conditions must be: (a) high cost or high volume or both; (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis; and (c) could reasonably have been prevented through the application of evidence-based guidelines. (See Premier CMS.)

HAC payment For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected HACs was not POA. That is, the case would be paid as though the secondary diagnosis was not present; however, if the patient has another coded complication (but not a HAC), the case will be paid at the higher DRG rate.

• FY 2008 IPPS CMS identified and approved an initial eight HACs, including three healthcare-associated infections (See HAI).
• FY 2009 IPPS In the IPPS rule taking effect October 1, 2008, CMS added two additional HACs to the original list of eight. The list of 10 now includes two new conditions (poor glycemic control and venous thromboembolism following certain orthopedic surgeries) and an expansion of one of the original eight, i.e., surgical site infection--mediastinitis, to include two more surgical sites--bariatric and certain orthopedic surgeries.
   

Healthcare-associated infections: The final list of 10 HACs includes three that are healthcare-associated infections. Asterisks indicate the new additions:

• Catheter-associated urinary tract infections. The ICD-9 code does not distinguish between catheter-associated infection and inflammation.
• Vascular catheter-associated blood stream infection (BSI). CMS now has a specific code for central-line vascular catheters (CVC). CVC-BSIs are not limited to the ICU.
• Surgical site infection. Two more SSIs have been added to mediastinitis:
  • Mediastinitis after CABG surgery. This infection has a specific complication code.
  • Selected orthopedic surgeries (spinal fusion and other surgeries of the shoulder and elbow).*
  • Bariatric surgery for morbid obesity – (laparoscopic gastric bypass and gastroenterostomy).*

Other hospital-acquired conditions All selections are from the National Quality Forum's list of 28 "Serious Reportable Events," frequently referred to as "Never Events":

• Object left in surgery (FY2009 refinement, a reaction to foreign substance accidentally left during a procedure).
• Air embolism.
• Blood incompatibility.
• Pressure ulcers (FY2009 refinement – Category III and IV only). (See Pressure ulcer.)
• Falls – Codes are not actually for "falls" but for potential adverse events or injuries occurring as the result of falls; injuries that should not occur during a patient’s hospitalization. The generic categories of coded injuries include fractures, dislocations, intracranial injury, crushing injury, burns, and other and unspecified effects of external causes. (See Falls.)
• Venous thromboembolism (VTE) after hip and knee replacement. Although VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE), CMS has only selected PE codes to which this payment policy applies at this time.* (See VTE.)
• Poor glycemic control – Ketoacidosis and Coma (hypoglycemic and hypoosmolar).*

Twenty three states change billing By mid August, hospitals in 23 states were not billing hospital patients for serious, preventable errors in some manner. Legislatures or state hospital associations in 23 states have approved reduced or non-payment policies for designated errors, up from 11 in February but with wide variance in their policies. Hospitals generally believe that patients and their families should have rapid and open communication regarding any serious, adverse event that may occur during hospitalization and that the purchaser of the healthcare services should not be charged for that care. However, many remain concerned that restricting payments will lead some providers to avoid high-risk patients, though others have expressed their support that states are doing this to improve transparency and compel care quality improvements.

Downloads and links

• Premier Safety Institute resources: CMS; HAI; Pressure ulcers; Falls; VTE;
• HAC-POA Indicators Web site
  http://www.cms.hhs.gov/HospitalAcqCond/

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Cleaning of patient rooms, a persistent challenge, prompts innovative methods to evaluate effectiveness

Several studies reveal that the persistence of microorganisms in the environment after patient room cleaning are found to often be related to the thoroughness of cleaning protocols. Recent studies that use tracer dyes to track and measure the effectiveness of cleaning processes are now taking on added importance.

Work published in 2006 by Philip Carling and colleagues addressed the transmission and persistence of microorganisms in the environment. To measure removal of microbes during cleaning, he developed a special "targeting solution," an environmentally stable, nontoxic material to which a chemical marker was added that fluoresces brightly when exposed to ultraviolet or "black" light. The material was developed so that it would be inconspicuous, dry rapidly on surfaces, remain environmentally stable for several weeks, and be easily removed with water-based cleaners. As described, the method can better measure effective cleaning by tracking removal of the targeted marker material sprayed on to selective surfaces. Carlings' 2008 study evaluated this method to determine the effectiveness of routine and terminal room cleaning disinfection on a larger scale. The solution was placed in randomly selected patient rooms and bathroom areas on high-risk objects in 23 acute care hospitals. The thoroughness of cleaning varied widely in some instances; results indicated that toilet handholds, bedpan cleaners, light switches, doorknobs, patient telephones, nurse call devices, and bedside rails were poorly cleaned. Sinks, toilet seats, and tray tables were found to be fairly well cleaned, but needed thorough cleaning with "elbow grease."

The importance of thorough cleaning was borne out in a recent study by Drees and colleagues using vancomycin-resistant enterococci (VRE) as a marker of room contamination, indicating that prior VRE room contamination was highly predictive of VRE acquisition; study authors urged increased attention to environmental cleaning and disinfection. The enforcement of environmental cleaning measures and cleaner healthcare worker hands was significantly associated with less surface contamination of VRE and a reduction in cross-transmission of VRE in an environment with a high level of endemic VRE.

Goodman and colleagues studied the relationship of environmental contamination and cleaning effectiveness by using both Carling's tracer dye solution and method along with environmental culturing of microorganisms, i.e, VRE and MRSA as markers. They investigated discharge room cleaning and the impact of a cleaning intervention measuring the removal of the tracer dye and MRSA and VRE cultures from selected surfaces in ICU rooms. The cleaning intervention included changing cleaning methods, an educational program, and feedback regarding the adequacy of the discharge cleaning. Results showed improvement in removal of both markers and target microorganisms. Researchers concluded that the change in cleaning methods, education and direct feedback reduce the room contamination measured by these markers.

Researchers state that the differences in cleaning of high-risk objects may be the result of a lack of knowledge of the importance certain objects have in the transmission of pathogens. They suggest that focused educational interventions with the environmental services staff could result in significant improvements in cleaning. Feedback from simple tracer markers using UV light appears to be highly effective in improvement of training in cleaning processes.

Downloads and links

• Carling AJIC 2006 abstract
• Carlings ICHE 2008 study
• Drees et al CID 2008
• Goodman ICHE 2008
• Premier Safety Institute Healthcare-associated infections (HAIs)
• Premier Safety Institute C. difficile

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Root cause analyses explain why and how adverse events occur; role in prevention unclear

Experts agree that root cause analysis (RCA) after an adverse event helps keep a focus on systems and process, not individual blame, leading to change in the safety culture. However, the actual contribution of RCA in reducing risk has not been studied.

RCA is a structured method used to retrospectively analyze serious adverse vents and is a required tool by the VA and The Joint Commission. Wu, Lipshutz, and Pronovost in early 2008 acknowledge its utility in answering key questions surrounding the AE, but they question whether its use in medicine has actually reduced the risk of AE reoccurrence.

Analysis of its use in the VA system by Mills et al does show that the RCA has been found to shift from individual blame and more to systemic causes, such as communication and policies. However, the identified weaknesses include an insufficient assessment of effect and outcomes of corrective action. Researchers also noted that there are no studies in the peer reviewed literature on the effectiveness of RCA in reducing risk or improving safety and no evaluations of the cost compared to other hazard mitigation tools. The JAMA commentary suggests that more emphasis should be placed on understanding variations in the implementation of RCA and developing a greater evidence base for the best way to conduct them.

In July 2008, Percarpio and colleagues published a literature review addressing similar questions, substantiating the observations that no controlled trials test the RCA framework. The case studies describe the typical safety improvements recommended following the use of RCA. Recommended improvements described include both clinical outcome measures and process measures. Other weaknesses include the selection of events for review, the variable quality of the analysis, lack of follow-up, and the potential for unintended consequences. They conclude, as did Wu et al., that formal studies at the system level as well as cost-benefit analyses are needed to determine the real effectiveness of RCA, noting that future research should focus studies that validate the RCA framework in improving patient safety and on the comparison of RCA with other analysis tools.

Downloads and links

• Wu JAMA Jan 2008
• Mills QSHC March 2008
• Percarpio JC QS July 2008

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Bar-coding surgical sponges significantly reduces risk of loss, researchers find

Bar-coded surgical sponges used during surgery detected more counting errors than traditional counting methods, whether cases of misplaced sponges or incorrect counts, according to researchers at Brigham and Women’s Hospital (BWH). Traditionally, surgical sponges have been manually counted along with instruments at the beginning and end of a surgical case. However, research has shown this method does not reliably prevent errors. The study by Greenberg et al. is a randomized, controlled trial comparing the incidence of misplaced and miscounted sponges in procedures using standard manual-count protocol with procedures where a bar-coded surgical sponge was used. Surgeons and operating room staff completed postoperative and end-of-study surveys evaluating the bar-code system in a total of 300 general surgery operations.

The bar-code system detected significant differences in counting 32 more discrepancies versus the traditional protocol (13). Discrepancies involved both misplaced sponges (21 vs. 12 sponges) and a highly significant difference in miscounted sponges (11 vs. 1 sponge). Resolution of the discrepancy took about the same time – 12 to 13 minutes. The bar-code system had technical difficulties being new, and increased the time spent counting sponges. But by the end of the study, the system was found to be easy to use, with providers feeling confident in its ability to track sponges and reporting a positive effect on the counting process. Researchers also reported that the system was easily implemented and well accepted. The results indicate the bar-coded sponges have significant potential to decrease the risk of retained sponges.

Downloads and links

• Greenberg et al Ann Surg 08 abstract.
• Premier Safety Institute Unique device identification (UDI), Bar coding of drugs, biologicals, devices

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Algorithm for selecting patient safety practices considers prevalence, cost, degree of complexity

Given the multiple sources for patient safety practices such as the Agency for Healthcare Research and Quality (AHRQ)  and NQF, a new AHRQ report examines which patient care interventions are actually being implemented. Although practices receiving the highest rating by clinicians for strength of evidence and potential impact tend to be clinical, actual implementation may be low. The authors proposed a framework for the selection of practices.

The AHRQ report describes a framework for choosing which patient safety interventions and specific patient safety practices should be considered for use in a hospital. A patient safety intervention is any intervention that decreases the probability of an adverse event occurring as a result of being exposed to the healthcare system. This includes, but is not restricted to, patient errors. In deciding upon the implementation of safety measures, it is not enough to just select evidence-based interventions. Intervention considerations should include the prevalence and severity of the safety problem targeted by an intervention, the potential for undesirable side effects of an intervention, the cost and complexity of effort to implement the intervention, the strength of the evidence, and the potential of the intervention to spur further safety initiatives. Additional issues to help decide which interventions to implement are the various types of personnel that may be needed for implementation, new education and training, impact on the workflow, and organizational culture changes, since not including these consideration results in less successful change implementation. The easiest changes to implement are those that fit in with what is already being done.

The authors of the review recommend that when deciding which interventions to implement, physicians should look at the tradeoff between the resources required to implement a safety intervention and the magnitude of the expected benefit. They recommend that hospitals use a combination of patient safety interventions that include:

1. Practices that are easy to implement and supported by strong evidence, such as:
   • In hospital: e.g., Ultrasound-guided central venous catheter insertion, prevention of catheter related bloodstream infection, and automatic stop orders to reduce urinary tract infections.
   • At discharge: Post discharge telephone calls to patients, structured discharge summaries, and structured handoff communications.
2. Practices with a smaller evidence base but likely to positively affect the hospital culture of safety, such as rapid response teams, executive walk rounds and teamwork training.
3. System-wide safety interventions such as computerized physician order entry (CPOE) and electronic health records (EHR).

Downloads and links

• AHRQ patient safety practices
• NQF patient safety practices
• AHRQ patient safety report - 75 practices Safety Institute Guidelines-AHRQ
• Ranjii abstract Med Clin 2008
• Premier Safety Institute Culture - Patient safety

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CABG mortality rates continue to improve despite decreasing volume

The volume of coronary artery bypass grafting (CABG) procedures performed at a particular facility may no longer be an accurate predictor of patient outcomes, according to a new study by Ricciardi and colleagues published in the Archives of Surgery (April, 2008). Researchers from Tufts University School of Medicine and the University of Minnesota found that the rate of CABG procedures increased from 7.2 cases per 1,000 discharges in 1988 to 12.2 cases per 1,000 discharges in 1997, and then decreased to 9.1 cases in 2003. However, CABG mortality rates fell from 5.4 percent in 1988 to 3.3 percent in 2003.

The researchers, using the Nationwide Inpatient Survey (NIS) data, examined a random sample of 108,087,386 patients, 1,082,218 of who underwent CABG in a 16-year period between 1988 and 2003. During this same time period, there were many improvements in minimally invasive approaches to coronary revascularization, enhancements in percutaneous transluminal coronary interventions (PTCI), the development of drug-impregnated stents, and new anticoagulant agents leading to a drop in the volume of CABG procedures. Previous literature indicated hospitals that performed a higher volume of CABG procedures had lower mortality rates. The Leapfrog Group established a standard of 500 CABG operations per year as quality criteria for selecting providers.

With the decrease in CABG volume, one would expect to see an increase in the mortality rate. This study was undertaken when no information could be found in a search of the literature describing outcomes related to the decreasing volumes. Researchers did find in-hospital CABG mortality rates are improving everywhere independent of CABG volume, however, and suspected that quality practices are improving as well. The lowest-volume hospitals had the largest reduction in CABG mortality, from 5.9 percent to 3.5 percent. This suggests that using volume as a cut-off point for regionalization of CABG care may not be necessary and in-hospital mortality rates following CABG may no longer be as useful as a quality benchmark. An invited critique by Dr. David Yuh of Johns Hopkins University adds that there is increasing experiential evidence that suggests hospital quality control programs, monitoring, and best practice programs may have a more significant effect on outcomes.

Downloads and links

• Ricciardi CABG ArchSurg abstract
• Premier Safety Institute – CMS; HAI

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Color-coded patient wristbands moving toward a national standard

A recent advisory from the American Hospital Association (AHA) requested all hospitals to begin using three standardized colors for wristbands that alert staff to specific conditions in order to improve patient safety. The colors, which have already been adopted in numerous states, include red for patient allergies, yellow for a fall risk and purple for “do not resuscitate” (DNR) patient preferences.

More than 25 state hospital associations have already provided their hospitals with voluntary guidelines on standardized patient wristband colors. Caregivers working in states that have adopted the wristband colors have welcomed the standardization and have reported reduced confusion caused by the numerous previous variations, according to the AHA.

Just one year ago, Safety Share reported that many states and regional groups that had adopted color coding completely agreed on red for allergies and yellow for fall risk. Nearly all had agreed on purple for DNR status. Much more variation in colors existed for latex and blood products – with most using clear or white for patient identification only. (See Premier Safety Share.)

In its advisory, the AHA points out that the wristbands function as an alert and patients’ status must always be verified.

Downloads and links

• AHA Advisory
• See Premier Safety Share

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Rationale for private rooms for patient safety explained

Hospitals have moved from large multi-bed wards with as many as 20 patients to semi-private or private rooms for those who could pay. Almost 90 years ago, it was proposed that single-patient rooms were the ideal setting to provide patient care. In the 2006 Guidelines for Design and Construction of Hospitals and Healthcare Facilities (the "Guidelines") used by nearly every state, a requirement for single rooms as a minimum standard was passed by consensus, but applied only in new construction. This standard was based on Single Room study commissioned by the Facilities Guidelines Institute to consider results for the 2006 guidelines, using evidence in the literature that supported this adoption.

A recent JAMA commentary by Detsky and Etchells noted that most modern hospitals have public value statements regarding safety, dignity, privacy, and patient-centered care. A tangible way to show commitment to these values would be to give patients their own bathroom in a single-patient room and ensure required patient privacy. As the JAMA commentary noted, "it is easier to build a single room once than to teach thousands of individuals to be attentive to patient privacy when patient care is provided in multi-bed rooms." Many reasons in favor of single-patient rooms for reducing infection include that they: reduce nosocomial infection rates, provided that other basic elements of infection control are in place; are easier to clean and decontaminate than multi-bed rooms; induce healthcare professionals to perform hand hygiene when moving between rooms rather than between bed; and obviate the need to move patients because of infection control or end-of-life care.

Although the authors cite the Guidelines single room requirement, they urge clinicians to advocate for single-patient rooms in any new hospital construction, expansion, renovation, or redesign and not wait 50 years for existing hospital structures to deteriorate before the full potential of single-patient rooms can be realized. The Guidelines are under revision for the 2010 edition, and open for public comment.

Downloads and links

• Premier Safety Institute - Single Room studies
• Detsky M; Etchells E JAMA abstract 2008
• See Safety Share July 2006 Private rooms are the standard for new construction to reduce medical errors and infection risks
• Premier Safety Institute - Single Room – Guidelines revision - Introduction

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CDC hand hygiene – Interactive training module, video, posters

The CDC Hand Hygiene Resource Web page provides an interactive training course on hand hygiene and other standard precautions to prevent healthcare associated infections. The course reviews key concepts of both hand hygiene and standard precautions. The learner is asked a series of hand hygiene questions as they work through the module and again at the end. The course also contains a short 60-second video on hand hygiene. Promotional materials can also be downloaded at http://www.cdc.gov/handhygiene/training/interactiveEducation/.

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AHRQ/RWJF – New patient safety resource for nurses in text or CD-ROM

AHRQ and the Robert Wood Johnson Foundation have jointly sponsored the development of a new patient safety resource for nurses. “Patient Safety and Quality: An Evidence-Based Handbook for Nurses” examines the broad range of issues involved in providing high quality and safe care across healthcare settings. This three-volume, 1,400-page handbook for nurses on patient safety and quality resources contains 89 contributions that represent the work of a broad range of nurses and other patient safety researchers throughout the nation. The handbook is grouped into six sections: Patient Safety and Quality; Evidence-based Practice; Patient-centered Care; Working Conditions and the Work Environment for Nurses; Critical Opportunities for Patient Safety and Quality Improvement; and Tools for Quality Improvement and Patient Safety. To review the publication, go to http://www.ahrq.gov/qual/nurseshdbk/ or obtain a print copy or CD-ROM by sending an e-mail to ahrqpubs@ahrq.hhs.gov.

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IHI tool – Adverse Events Prevented Calculator supports quality business case

To assist institutions in making the business case for quality programs, the Institute for Healthcare Improvement (IHI) is unveiling the Adverse Events Prevented Calculator. This tool helps model the financial implications of reductions in adverse event rates in an organization and assists in translating actual and potential improvement results into projected lives and dollars saved. The tool allows one to track the change in rate of any one type of adverse event over time and, when appropriate additional data are added, the consequent change in unnecessary deaths ("lives saved"), real and additional potential cost savings ("dark green dollar" savings and "light green dollar" savings, respectively), and the return on investment of quality improvement work targeting those adverse events. Download the tool at http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/adverseeventspreventedcalculator.htm.

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RWJF - Free toolkit to implement quality improvement program

The Robert Wood Johnson Foundation has released a free toolkit, Transforming Care at the Bedside (TCBA), this model program engages nurses and leaders at all levels of the organization to improve the quality and safety of patient care on medical and surgical units. Ten hospitals graduated from the third phase of the five-year program in May. TCAB is not a traditional quality improvement program; one primary characteristic that sets it apart is its focus on engaging frontline staff and unit managers. Ideas for transforming the way care is delivered on medical/surgical units come from the nurses and other care team members who spend the most time with patients and their families.

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Premier Safety Institute – QI and patient education tools for VTE prevention

The Premier Safety Institute has updated its Venous Thromboembolism (VTE) module  to include resources and guidelines for: VTE prevention, VTE toolkits, education programs, and national initiatives and toolkits. Available resources include

• An audio-conference with downloadable materials, including DVT research slides, physician and nurse assessments, sample order sets, and a recording of the audio conference.
• A webcast on anticoagulation therapy includes speakers from hospitals with successful anticoagulation therapy programs who share their journey to reduce adverse events and discuss The Joint Commission's 2008 National Patient Safety Goals for anticoagulation therapy. Slides and an audio file of the webcast and other resources also are available.
• An Informatics comparative data tools help users identify potential problems, track progress and monitor variations, enabling users to actively reduce the rates of DVT and other serious avoidable conditions, establish performance benchmarks and share best practice interventions.
• Premier’s "Performance Improvement Portal" is a resource for clinicians to get information on performance improvement advice and best practices on key clinical quality and safety issues, including prevention of VTE.
• AHRQ Consumer’s Guide –just released in August 2008 Your Guide to Preventing and Treating Blood Clots.

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