Root cause analysis (RCA) of all hospital associated venous thromboembolism is a requirement of the NHS Standard Contract.

RCA is a well-established investigation methodology which explores the how, what, and why of patient safety incidents. The technique uses a structured process to move beyond identifying what went wrong and helps identify the contributory factors and root causes of patient safety incidents.

Using RCA for hospital associated thrombosis (HAT) provides a systematic and evidence based method for finding out what factors or events lead to a patient suffering a VTE. The result will help organisations gain a better understanding of the contributory factors and causes associated with VTE events and enable them to take action to reduce the risk of VTE in the future.

RCA may be completed for...
  • Patients who develop a VTE within three months of admission or surgery
  • Inpatients who develop a VTE
  • Complaints identifying VTE as an issue
  • Sudden death of a patient where VTE is a suspected or proven cause of death
  • Pregnant women or post-natal within three months presenting or dying from a VTE

If completion of an RCA reveals that VTE prevention care has been inadequate, duty of candour may apply.

Below are some tools that might be useful in implementing HAT RCA.

HAT RCA standard operating procedure Reducing Venous Thromboembolism. Root Cause Analysis Tools. NPSA 2010.

Hospital associated thrombosis RCA templates

HATs RCA form template example 1 HATs RCA form template example 2

Duty of Candour

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20, set out specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.

Best practice guidelines are available to guide VTE prevention care. Where best practice guidelines have not been adhered to and a patient develops a VTE, duty of candour should be initiated and the relevant patient safety investigation carried out.

The Cost of VTE

Information on the cost of hospital associated VTE legal claims can be found here.