Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Venous Thromboembolism

Objective To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from venous thromboembolism (VTE) by the California Pregnancy-Associated Mortality Review Committee. Design Qualitative, descriptive design using thematic analysis. Sample A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007. Methods We coded and thematically organized the 108 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. Results Women's lack of awareness of the significance of severe VTE symptoms and the lack of a standardized approach to recognize and respond to VTE signs and symptoms were the most prevalent themes in the Readiness domain. Missing the signs and symptoms of VTE and the resultant missed or delayed diagnosis were predominant themes in the Recognition domain. For Response, issues related to lack of VTE prophylaxis were most frequently noted, along with other themes, including timing of treatment and appropriate follow-up after hospital discharge. Conclusion To decrease the occurrence of maternal death from VTE in the United States, consistent and thorough education regarding VTE signs and symptoms must be given to all women and their families during pregnancy and the postpartum period. Maternity care facilities and providers should implement preventive measures, including standardized use of VTE prophylaxis, improved methods to recognize the signs and symptoms of VTE, and improved follow-up after hospital discharge.