Source · HSSIB Patient Safety Investigation
The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period
Published 8 December 2022
Launched 18 May 2022
Published
HSIB Legacy
Maternity
Venous thromboembolism is the collective term for the formation of blood clots. Pregnant women could suffer a potentially fatal blood vessel blockage if their risk is not properly assessed during pregnancy and the first six weeks after birth.
Summary
3 observations
Safety Observations
Observation 1
Observation
It may be beneficial for organisations to consider guidance, such as the ‘principles for effectiveness and usability’ provided by the Chartered Institute of Ergonomics and Human Factors, when developing risk assessment tools. The aim being to ensure assessments are simple to use and therefore staff being more likely to do them thoroughly and avoid tick-box fatigue.
Observation 2
Observation
It may be beneficial for organisations that make recommendations to improve the safety and care of pregnant women and pregnant people during their pregnancy and up to 6 weeks after birth, to have a process for reporting on responses to their recommendations. This would support transparency, making it easy to see what has been achieved and what remains outstanding. The aim being to enable tracking of the implementation of actions designed to improve safety and outcomes to ensure they happen.
Observation 3
Observation
It may be beneficial if future research or funding is directed towards identifying the evidence base for the prescribing of low-molecular-weight heparin for venous thromboembolism risk in pregnancy and the first 6 weeks after birth. This will support the production of evidence-based clinical