Monitoring Practice

It is important for facilities to monitor VTE prevention processes and cases of VTE. Feedback from this should be passed on to clinicians to drive change and raise awareness. All clinicians should also be educated on VTE prevention processes and the preventable nature of VTE. To assist, the CEC has made available a number of tools and systems.

Reporting Adverse Events

Any significant unexpected change in a patient's condition relating to VTE prophylaxis including embolism and bleeding, should be considered an adverse event and be recorded in the Incident Monitoring System (IIMS).

All patients who present on admission with a VTE resulting from a previous hospitalisation (within 90 days of discharge), or who develop a VTE during hospitalisation must have the incident documented in the patient's health care record and recorded into IIMS.

IIMS NSW Health employees can submit VTE related incidents here.

To standardise the way incidents of VTE are investigated, the CEC has developed a Non-Fatal VTE Incident Management Tool. This tool can be used to guide investigation of cases of VTE to determine whether the VTE could have been prevented and if the appropriate VTE prevention strategies are in place.

Monitoring Incidents

A VTE Database is available to LHDs/SNs and their facilities to monitor rates of hospital-associated VTEs. The database extracts ICD-10 coded data from Health Information Exchange (HIE). Incidents can be viewed on LHD, facility or ward level, and be benchmarked against Peer Hospitals or NSW average.

Access to the database can be obtained by emailing us.

Clinical Audit

The Quality Audit Reporting System (QARS) has been developed by the Clinical Excellence Commission to provide local health districts (LHDs) and speciality networks (SNs), and their facilities with a tool to conduct quality audits to provide evidence for the accreditation process, evaluate performance and initiate relevant action plans. The QARS allows evaluation at LHD, facility or ward levels. Benchmarking against the NSW average and peer groups is also available.

A simple VTE Prevention questionnaire is available within QARS to assist facilities with assessing compliance with the Policy Directive: Prevention of Venous Thromboembolism (PD2014_032). The questionnaire can be modified by adding or removing questions to suit local needs. It is recommended that clinical audit be conducted at least annually or more frequently where compliance is poor.

Before commencing a VTE audit in the QARS, please read the user manual, which can be accessed by selecting 'Help' on the Home Page (see image below).

QARS - user manual

An Auditor Reference Guide for the VTE Prevention questionnaire has been developed to provide guidance for the auditor and assist with the interpretation of percentages in the 'Compliance Rate of Audit by Question' report. This report can be generated by accessing the 'Reports' function in the QARS.

For more information or to obtain access, please contact your LHD's QARS administrator, or the CEC via email

In addition, other audit measures are available to facilities to VTE processes, including: