Background
Acute Venous Thromboembolism (VTE) is the third most common cardiovascular disease after stroke and myocardial infarction. Pulmonary Embolism (PE), the most critical manifestation of VTE, requires timely diagnosis and initiation of treatment to prevent morbidity and mortality.
Victorian sentinel events related to PE reported to Safer Care Victoria between July 2021 and November 2024 were analysed for recurring care issues. 23 sentinel events involving PE were identified, and 22 cases involved intermediate-risk PE progressing to high-risk PE.
Analysis of PE-related sentinel events allows a unique insight into PE-related care challenges within the Victorian context. Data from these events informed conversations with Victorian PE clinicians and the development of PE Practice Points for dissemination to Victorian Health Services.
Acknowledgments
Thank you to Dr Elleanor Lee, Honorary Appointee, Safer Care Victoria Sentinel Events Program and Emergency Physician at Barwon Health for authoring these Practice Points and undertaking the analysis and evaluation.
Thank you also to the Health Services and Clinicians who dedicated their time and contributed to this project. In graciously sharing the expertise and bodies of personal work, the current state and opportunities in PE care are better understood for all to benefit from.
Most importantly, we want to acknowledge the experiences of the patients, families, carers, healthcare workers, and health services involved in these sentinel events, and we are grateful for the opportunity to learn from these reviews and improve PE care for all Victorians.