Journal of General Internal Medicine

, Volume 27, Issue 3, pp 318–324 | Cite as

Unintended Consequences of a Standard Admission Order Set on Venous Thromboembolism Prophylaxis and Patient Outcomes

  • Raman Khanna
  • Eric Vittinghoff
  • Judith Maselli
  • Andrew Auerbach
Original Research



Standard order sets often increase the use of desirable interventions for patients likely to benefit from them. Whether such order sets also increase misuse of these interventions in patients potentially harmed by them is unknown. We measured the association between a paper-based standard admission order set with a venous thromboembolism pharmacoprophylaxis (VTEP) module and use of VTEP for patients likely to benefit from it as well as patients with unclear benefit or potential harm from it.


We conducted a retrospective cohort study using administrative and pharmacy charge data of patients admitted between 1 July 2005 and 31 December 2008 to two medical and three surgical services that implemented a standard admission order set in August 2006. The primary outcome was use of VTEP in patients with likely benefit, unclear benefit, and potential harm from VTEP prior to and following order set implementation.


A total of 8,429 patients (32%) were admitted prior to and 17,635 (68%) following order set implementation. There was a small unadjusted rise in overall VTEP use after implementation (51% to 58%, p < 0.001). In multivariable models with interrupted time series analysis, patients with potential harm from VTEP had the largest increase in VTEP use at the time of implementation [adjusted odds ratio = 1.58; 95% confidence interval (CI), 1.12–2.22]. The increased likelihood of receiving VTEP in this subgroup gradually returned to baseline (adjusted odds ratio per month = 0.98; 95% CI, 0.96–0.99).


Implementation of a standard admission order set transiently increased VTEP in patients with potential harm from it. Order set and guideline success should be judged based on the degree to which they successfully target patients likely to benefit from the intervention without inadvertently targeting patients potentially harmed.


quality improvement thromboembolism hospital medicine outcomes 



The authors would like to thank Arjang Ahmadpour and Benjamin Vidalis for their invaluable help in organizing and preparing charts for the chart review.

Funding Source

Dr. Auerbach was supported by grant K24 HL098372-01 from the National Heart, Blood, Lung Institute.

Conflicts of Interest

None disclosed.

Supplementary material

11606_2011_1871_MOESM1_ESM.pdf (180 kb)
(PDF 180 kb)
11606_2011_1871_MOESM2_ESM.doc (34 kb)
(DOC 34 kb)


  1. 1.
    Maynard G, Stein J. Designing and implementing effective venous thromboembolism prevention protocols: lessons from collaborative efforts. J Thromb Thrombolysis. 29(2):159–66.Google Scholar
  2. 2.
    O'Connor C, Adhikari NK, DeCaire K, Friedrich JO. Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes. J Hosp Med. 2009;4(2):81–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Maynard G, Wesorick DH, O'Malley C, Inzucchi SE. Subcutaneous insulin order sets and protocols: effective design and implementation strategies. J Hosp Med. 2008;3(5 Suppl):29–41.PubMedCrossRefGoogle Scholar
  4. 4.
    Thompson R, Schreuder AB, Wisse B, et al. Improving insulin ordering safely: the development of an inpatient glycemic control program. J Hosp Med. 2009;4(7):E30–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Thiel SW, Asghar MF, Micek ST, Reichley RM, Doherty JA, Kollef MH. Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis. Crit Care Med. 2009;37(3):819–24.PubMedCrossRefGoogle Scholar
  6. 6.
    Micek ST, Roubinian N, Heuring T, et al. Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med. 2006;34(11):2707–13.PubMedCrossRefGoogle Scholar
  7. 7.
    Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608–13.PubMedCrossRefGoogle Scholar
  8. 8.
    Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA. 2006;296(4):427–40.PubMedCrossRefGoogle Scholar
  9. 9.
    Larson DM, Menssen KM, Sharkey SW, et al. "False-positive" cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298(23):2754–60.PubMedCrossRefGoogle Scholar
  10. 10.
    Pletcher MJ, Fernandez A, May TA, et al. Unintended consequences of a quality improvement program designed to improve treatment of alcohol withdrawal in hospitalized patients. Jt Comm J Qual Patient Saf. 2005;31(3):148–57.PubMedGoogle Scholar
  11. 11.
    Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med. 2008;149(1):29–32.PubMedGoogle Scholar
  12. 12.
    Auerbach AD, Chlouber R, Singler J, Lurie JD, Bostrom A, Wachter RM. Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21(10):1079–85.PubMedCrossRefGoogle Scholar
  13. 13.
    Shojania KG, Duncan BW, McDonald KM, Wachter RM. Safe but sound: patient safety meets evidence-based medicine. JAMA. 2002;288(4):508–13.PubMedCrossRefGoogle Scholar
  14. 14.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27.PubMedCrossRefGoogle Scholar
  15. 15.
    Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330(7494):765.PubMedCrossRefGoogle Scholar
  16. 16.
    Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):338S–400S.PubMedCrossRefGoogle Scholar
  17. 17.
    Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods. 2002;7(2):147–77.PubMedCrossRefGoogle Scholar
  18. 18.
    Hopke PK, Liu C, Rubin DB. Multiple imputation for multivariate data with missing and below-threshold measurements: time-series concentrations of pollutants in the Arctic. Biometrics. 2001;57(1):22–33.PubMedCrossRefGoogle Scholar
  19. 19.
    Rubin DB, Schenker N. Multiple imputation in health-care databases: an overview and some applications. Stat Med. 1991;10(4):585–98.PubMedCrossRefGoogle Scholar
  20. 20.
    Belin TR, Diffendal GJ, Mack S, Rubin DB, Schafer JL, Zaslavsky AM. Hierarchical logistic regression models for imputation of unresolved enumeration status in undercount estimation. J Am Stat Assoc. 1993;88(423):1,149–66.Google Scholar
  21. 21.
    West SG, Duan N, Pequegnat W, et al. Alternatives to the randomized controlled trial. Am J Public Health. 2008;98(8):1359–66.PubMedCrossRefGoogle Scholar
  22. 22.
    Shadish WR, Cook TD, Campbell DT. Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston, MA: Houghton-Mifflin; 2002.Google Scholar
  23. 23.
    Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373–79.PubMedCrossRefGoogle Scholar
  24. 24.
    Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol. 2007;165(6):710–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Baroletti S, Munz K, Sonis J, et al. Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study. J Thromb Thrombolysis. 2008;25(2):146–50.PubMedCrossRefGoogle Scholar
  26. 26.
    McGarry LJ, Stokes ME, Thompson D. Outcomes of thromboprophylaxis with enoxaparin vs. unfractionated heparin in medical inpatients. Thromb J. 2006;4:17.PubMedCrossRefGoogle Scholar
  27. 27.
    Maynard G, Stein J. Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. Prepared by the Society of Hospital Medicine. AHRQ Publication No. 08–0075. Rockville, MD: Agency for Healthcare Research and Quality. August 2008.Google Scholar
  28. 28.
    Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146(4):278–88.PubMedGoogle Scholar
  29. 29.
    Andrade SE, Gurwitz JH, Chan KA, et al. Validation of diagnoses of peptic ulcers and bleeding from administrative databases: a multi-health maintenance organization study. J Clin Epidemiol. 2002;55(3):310–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Abdel-Razeq H. Venous thromboembolism prophylaxis for hospitalized medical patients, current status and strategies to improve. Ann Thorac Med. Oct;5(4):195–200.Google Scholar
  31. 31.
    Longcamp M, Boucard C, Gilhodes JC, et al. Learning through hand- or typewriting influences visual recognition of new graphic shapes: behavioral and functional imaging evidence. J Cogn Neurosci. 2008;20(5):802–15.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Raman Khanna
    • 1
  • Eric Vittinghoff
    • 2
  • Judith Maselli
    • 3
  • Andrew Auerbach
    • 1
  1. 1.Division of Hospital MedicineUniversity of CaliforniaSan FranciscoUSA
  2. 2.Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoUSA
  3. 3.Division of General Internal MedicineUniversity of CaliforniaSan FranciscoUSA

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