**7. Treatment with other drugs**

In 12 cases the VTE was thought to be caused by other drugs (Table 4). It was mainly claims with faulty use of anticoagulants that were approved. One patient died.


Table 4. The other drugs involved in VTE claims.

Non-operative treatment of fractures and joint injuries was the cause of 30 claims, shown in table 5.


Table 5. VTE after non-operative treatment.

It was of course mainly fractures in the lower extremity that were afflicted because of the need for immobilization. Usually in the DPIA, VTE is thought to be a side effect of the fracture itself, and it is therefore not eligible for compensation. In 4 cases however, the diagnosis was missed, and in one further case the appeal board decided that the diagnosis should have been made at the time, when the cast was cut open because of swelling. In the last 9 approved cases there were individual indications for giving anticoagulants that were not recognized at the time of fracture. Four patients died as a result of the patient injury. In many of the non-approved cases, the question was whether the experienced specialist

Venous Thromboembolism as a Preventable Patient Injury:

prophylaxis for the period they are at risk?

the administration of medication simpler (5, 6).

contraceptive drugs more often.

of the DPIA to approve these claims.

**10. Discussion** 

Experience of the Danish Patient Insurance Association (1996 - 2010) 165

The standard prophylaxis in Denmark is usually given only for the duration of admittance to hospital, or until the patient is well mobilized. During recent times, a number of studies have suggested that this is not enough, and that prophylaxis should be given for 6 or 8 weeks after surgery (3, 4). The price would be manageable, and the logistics could probably be overcome. Why do we accept that hundreds and hundreds of patients go without

Also, it is not rare to see a patient described as "well mobilized" and therefore have his prophylaxis discontinued, when in fact he is only out of bed for a few hours a day and then only sitting in a chair. The sitting position, if anything, increases the stasis of blood in the veins of the legs, and therefore probably also increases the risk of VTE. The development of tablets for VTE prophylaxis may change this state of affairs in the future, since it will make

The treatment of VTE goes hand in hand with the prevention of the disease. When you have seen the damage that VTE can do to patients, you are likely to go far to prevent a single case. There exists well-proven mechanical as well as biochemical methods with very few side effects. All of these 688 cases must be viewed as potentially preventable with the exception of the 3 cases, where VTA occurred in spite of the fact that correct prophylaxis was given. Off course it is not possible to prevent all cases, which you can se by the fact that these 3

It is inexcusable to perform major invasive treatment without prophylaxis, and probably the medical profession should consider extending the indications as well as the duration of prophylaxis. The cost of doing this will be balanced against the gain from not having to treat

It should probably also be considered to screen the women for coagulation deficits before they are placed on contraceptive medication. Certainly, it is clear from our records, that the medical profession should consider the differential diagnosis of VTE in patients on

For the DPIA it is also a question whether you should approve claims from women, who have a coagulation defect like Leiden factor-5 mutation? There were only 17 cases where our patients had been tested positive for this genetic defect. The true number is probably much higher. Normally, the DPIA does not approve claims, when a patient has a disposition to the injury. It can be argued, however, that the experienced specialist would not prescribe contraceptive drugs to a patient with Leiden-5 mutation. It is therefore the normal practice

The fractures that are treated by non-invasive means are by no means immune from VTE. A recent metaanalysis of the question of prophylaxis to these patients (8) states that ambulatory patients with temporary lower leg immobilization who are over 50, in a rigid cast, non-weight bearing or with a severe injury should be considered as a risk group for VTE. The present opinion is however, that the VTE in these cases is caused by the trauma and not the treatment. The patient that dies from PE probably doesn't care. We think that it

should be seriously considered to include these patients in an anti-VTE program.

cases occurred. But this must not be given as an excuse to omit prophylaxis.

the VTE-cases and the tax returns from the survivors of complications to VTE (7).

would have used prophylaxis? For example, the recommended program for a non-displaced fracture of the tibia states that prophylaxis against VTE is not necessary; yet the frequency of DVT in these patients is 15 %. If we were to extend the program of prophylaxis to encompass ambulatory patients with a walking cast, these patients would only rarely suffer DVT, and some lives would be spared.
