CLN-SOP-005: Venous thromboembolism risk assessment and prophylaxis

Standards › Standard 1 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · CLN-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 1.7

At a glance

Every patient is assessed for clot risk on admission and before surgery.
At-risk patients have prophylaxis prescribed and given.
Mechanical prophylaxis is used where drugs are not suitable.
Each decision is recorded.
Stop and get help straight away if: an at-risk patient has no prophylaxis and no recorded reason.

1. Purpose

To prevent blood clots that can reach the lungs and cause death (1.7).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

Blood clots in the legs that reach the lungs can kill a patient who looked well. Assessing every patient before admission and before surgery, and preventing clots in those at risk, is one of the most effective safety measures.

5. Responsibilities

Role	Responsibility	Competence
Admitting clinician	Assesses clot risk and prescribes prophylaxis	Doctor
Ward nurse	Gives prophylaxis and checks the record	Nurse

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Assess.

Assess each patient for clot risk on admission and before any surgery (CLN-FRM-007).

Key point: Every patient, every time.

Step 2. Prescribe.

Prescribe pharmacological or mechanical prophylaxis for each at-risk patient.
Record the reason if none is given.

Key point: A decision is always recorded.

Step 3. Give and check.

Give the prophylaxis as prescribed and check the record each shift.

Key point: Given as prescribed.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Patients assessed on admission and before surgery	100%	Monthly	Clinical director	Escalate to chief executive
At-risk patients with prophylaxis given or reason recorded	100%	Monthly	Clinical director	Escalate to chief executive

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
CLN-FRM-007	VTE risk assessment record	Record
HOS-SOP-006	High-alert medicines	Medicines

17. Evidence

Reference	Note
E-009	Based on NICE guideline NG89 on venous thromboembolism (2018).
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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