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Research

Original Investigation | PACIFIC COAST SURGICAL ASSOCIATION

Correlation of Missed Doses of Enoxaparin


With Increased Incidence of Deep Vein Thrombosis
in Trauma and General Surgery Patients
Scott G. Louis, MD; Misa Sato; Travis Geraci, MD; Ross Anderson, BS; S. David Cho, MD; Philbert Y. Van, MD;
Jeffrey S. Barton, MD; Gordon M. Riha, MD; Samantha Underwood, MS; Jerome Differding, MPH;
Jennifer M. Watters, MD; Martin A. Schreiber, MD

IMPORTANCE Enoxaparin sodium is widely used for deep vein thrombosis (DVT) prophylaxis,

yet DVT rates remain high in the trauma and general surgery populations. Missed doses
during hospitalization are common.

Invited Commentary
page 370
CME Quiz at
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CME Questions page 408

OBJECTIVE To determine if missed doses of enoxaparin correlate with DVT formation.


DESIGN, SETTING, AND PARTICIPANTS Data were prospectively collected among 202 trauma
and general surgery patients admitted to a level I trauma center.
MAIN OUTCOMES AND MEASURES Deep vein thrombosis screening was performed using a

rigorous standardized protocol.


RESULTS The overall incidence of DVT was 15.8%. In total, 58.9% of patients missed at least 1

dose of enoxaparin. The DVTs occurred in 23.5% of patients who missed at least 1 dose and in
4.8% of patients who did not (P < .01). On univariate analysis, the need for mechanical
ventilation (71.8% vs 44.1%), the performance of more than 1 operation (59.3% vs 40.0%),
and male sex (75% vs 56%) were associated with DVT formation (P < .05 for all). A bivariate
logistic regression was then performed, which revealed age 50 years or older and interrupted
enoxaparin therapy as the only independent risk factors for DVT formation. The DVT rate did
not differ between trauma and general surgery populations or in patients receiving once-daily
vs twice-daily dosing regimens.
CONCLUSIONS AND RELEVANCE Interrupted enoxaparin therapy and age 50 years or older are
associated with DVT formation among trauma and general surgery patients. Missed doses
occur commonly and are the only identified risk factor for DVT that can be ameliorated by
physicians. Efforts to minimize interrupted enoxaparin prophylaxis in patients at risk for DVT
should be optimized.
JAMA Surg. 2014;149(4):365-370. doi:10.1001/jamasurg.2013.3963
Published online February 26, 2014.

eep vein thrombosis (DVT) and venous thromboembolism (VTE) in critically ill or injured patients remain a major concern.1,2 Trauma and general surgery
patients have a multitude of factors contributing to VTE, including venous stasis, endothelial injury, impaired fibrinolysis, and decreased levels of serum anticoagulants. Despite standard prophylaxis, the incidence of pulmonary embolus after
trauma has been reported to be as high as 2% to 22%.3,4 It is
the third most common cause of death among patients with
major trauma surviving the first 24 hours and is the second
most common medical complication among postoperative patients in the United States.5,6 The incidence of DVT is estijamasurgery.com

Author Affiliations: Trauma


Research Institute of Oregon, Oregon
Health & Science University, Portland.
Corresponding Author: Scott G.
Louis, MD, Trauma Research Institute
of Oregon, Oregon Health & Science
University, 3181 SW Sam Jackson Park
Rd, Mail Code L223A, Portland, OR
97239 (louis@ohsu.edu).

mated to be as high as 60% among trauma patients not receiving prophylactic anticoagulation.6 In addition, VTE represents
a significant cause of preventable health care expenditure, with
estimated inpatient management costs of up to $17 000.7
Low-molecular-weight heparin (LMWH) has emerged as
a safe and effective modality for the prevention of VTE. In patients undergoing abdominal and pelvic surgery, LMWH has
been shown to reduce the risk of symptomatic VTE by 80%.8
Although little high-quality evidence exists in the trauma population, LMWH therapy has been estimated to prevent 4 to 10
times as many nonfatal VTE events as nonfatal bleeding complications in these patients.9 The LMWH enoxaparin sodium
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365

Research Original Investigation

Doses of Enoxaparin and Increased Incidence of DVT

Table 1. Characteristics of Patients With vs Without Deep Vein Thrombosis


No Deep Vein
Thrombosis
(n = 170)

Characteristic

Deep Vein
Thrombosis
(n = 32)

Age, mean (SD), y

55 (17)

58 (14)

.37

Male sex, %

75

56

.05

P Value

Ventilator support, %

71.8

44.1

.006

Trauma, %

40

35

.54

BMI, mean (SD)

36.9 (11.9)

33.0 (11.2)

APACHE II score, mean (SD)

15 (7)

13 (7)

Hospital length of stay, median (IQR), d

33 (26-40)

20 (10-35)

<.001

Duration of enoxaparin sodium therapy, median (IQR), d

29 (19-35)

16 (8-29)

.001

has been extensively studied and has been proven effective in


the prevention of DVT.10
During hospitalization, intermittent interruption of enoxaparin therapy is common. Patients miss doses for various reasons, including preoperative interruption, patient refusal, and
nursing errors. Interruption of therapy has recently been shown
to correlate with increased incidence of DVT in patients with
traumatic brain injury.11 To date, this has not been studied in
the larger trauma and general surgery populations. We hypothesized that an increase in DVT incidence would be seen
among trauma and general surgery patients with interrupted
enoxaparin dosing during hospitalization.

.06
.30

Abbreviations: APACHE II, Acute


Physiology and Chronic Health
Evaluation II; BMI, body mass index
(calculated as weight in kilograms
divided by height in meters squared);
IQR, interquartile range.

Bilateral whole-leg duplex ultrasonography for DVT surveillance was performed per a rigorous institutional protocol, which included weekly ultrasonography for patients
admitted to the intensive care unit and for patients admitted to the trauma ward. General surgery patients on
the acute care ward were screened when DVT was suspected by the primary treatment team. Upper extremity and
neck ultrasonography was performed on an as-needed basis
when DVT was suspected. Computed tomographic angiography was performed when pulmonary embolus was
suspected.

Statistical Analysis

Methods
This study was approved by the institutional review board at
Oregon Health & Science University. The level I trauma center at the university abides by the current federal Health Insurance Portability and Accountability Act guidelines. Informed written consent to participate was obtained from each
patient or from a legal representative.

Patient Selection
Patients admitted to the trauma center at Oregon Health & Science University who were ordered to receive prophylactic enoxaparin were eligible for enrollment. Patients received at least 1
dose of prophylactic enoxaparin to be considered for the study.
All prophylactic dosing regimens were included, including oncedaily, twice-daily, and dosing adjusted for renal impairment and
obesity. Patients receiving therapeutic enoxaparin for nonthrombotic indications were eligible for enrollment. Patients
were excluded for any known thromboembolic diagnoses or for
the use of anticoagulants other than enoxaparin.

Study Variables
Patient characteristics were recorded, including age, sex,
weight, body mass index (BMI), and ventilator support. Also
collected were data on injuries, operations, significant comorbidities, trauma or surgical intensive care unit status, and the
Acute Physiology and Chronic Health Evaluation II (APACHE
II) score. Recorded were the time of blood draws, the time and
dose of enoxaparin administration, and the type and location
of intravenous access used to obtain blood.
366

A database was maintained using a spreadsheet (Microsoft Excel; Microsoft Corporation). Statistical analyses were performed using a software program (SPSS 19; SPSS, Inc). Continuous data were analyzed using t test or Mann-Whitney test
where appropriate. Categorical data were analyzed using 2 test
or Fisher exact test where appropriate. Logistic regression was
performed in a standard bivariate fashion. Significance was defined as P < .05.

Results
Study Sample
Data from 202 trauma and general surgery patients were collected during a 4-year period from February 2007 through September 2012. The mean (SD) values for the cohort were 56 (1)
years for age, 14 (1) for the APACHE II score, and 33.7 (0.8) for
BMI (calculated as weight in kilograms divided by height in meters squared). There were 73 trauma patients and 129 general
surgery patients, and 58.9% were men. A review of the duplex ultrasonography examinations revealed a DVT rate of
15.8%. No significant differences were observed in age, BMI,
or APACHE II score between the patients with vs without DVT.
Men were more likely than women to develop DVT (Table 1).
No pulmonary emboli were diagnosed among the cohort during the study period.

Characteristics of Therapy
Patients who developed DVT and patients who did not were
divided into 2 groups. Both groups had a median duration to
initiation of enoxaparin therapy of 2 days. As summarized in

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Doses of Enoxaparin and Increased Incidence of DVT

Original Investigation Research

Table 2. Documented Reasons for Interruption of Enoxaparin Sodium Therapy and the Total Dose
Withheld Among Trauma and General Surgery Patients
Variable

Trauma

General Surgery

P Value

Documented reason, %
Pending invasive procedure

41.6

36.8

.44

None

27.1

31.9

.76

Patient absent from the room

11.7

11.4

.82

Concern about bleeding

12.1

2.9

.02

Epidural catheter removal

5.9

13.7

.16

Physician or nursing error

1.6

3.3

.10

Total dose withheld, median (IQR), mg

120 (60-240)

120 (40-360)

Abbreviation: IQR, interquartile


range.

.66

Table 3. Coagulation Data Relative to Uninterrupted vs Interrupted Enoxaparin Sodium Therapy


Mean (IQR)
Variable

Uninterrupted
(n = 83)

Interrupted
(n = 119)

International normalized ratio

1.05 (1.00-1.10)

1.20 (1.17-1.30)

.12

Partial thromboplastin time, s

33.3 (27.5-36.5)

33.1 (29.1-37.1)

.84

625.7 (531.8-719.6)

715.1 (636.3-737.1)

Fibrinogen level, mg/dL


Platelet count, 103/L

225 (192-258)

Table 1, the group diagnosed as having DVT had a longer total


hospital length of stay and a longer duration of enoxaparin
therapy.

237 (195-279)

At least 1 enoxaparin dose was missed in 58.9% of patients.


Most of those missed 4 or fewer doses; however, there was significant variability in the number of doses missed. Twentyeight patients missed 1 dose, 17 missed 2 doses, 19 missed 3
doses, 10 missed 4 doses, 4 missed 5 doses, 5 missed 6 doses,
4 missed 7 doses, 2 missed 8 doses, 5 missed 9 doses, 3 missed
10 doses, and 22 missed more than 10 doses. The most common reason indicated for interruption of therapy was for a
pending invasive procedure (Table 2). Trauma patients were
more likely to have doses withheld because of concern for
bleeding, but all other reasons for interruption of therapy were
similar for trauma and general surgical patients. Patients who
had uninterrupted enoxaparin therapy were compared with
those who had therapy interrupted at least once. A 4.8% DVT
rate was observed in the uninterrupted therapy group, and a
23.5% DVT rate was observed in the interrupted therapy group
(P < .01). Patients not diagnosed as having DVT were much less
likely to miss doses than those diagnosed as having DVT (50.8%
vs 88.2%) (P > .001). No differences were observed between
patients with uninterrupted therapy and those with missed
doses in measured coagulation variables, including the mean
platelet count, fibrinogen level, partial thromboplastin time,
and international normalized ratio (Table 3).
A univariate logistic regression was performed to assess
the effect of increasing number of missed enoxaparin doses
on the development of DVT. As shown in Table 4, missing 1 dose
did not significantly alter the likelihood of DVT. However, a direct correlation was observed between the number of missed
doses and the risk of DVT starting at 2 doses missed. After 18
doses missed, this relationship ceased to exist, likely because
of the small sample size.
jamasurgery.com

SI conversion factors: To convert


fibrinogen level to micromoles per
liter, multiply by 0.0294; to convert
platelet count to 109/L, multiply
by 1.0.

.07
.65

Table 4. Univariate Logistic Regression Analyzing the Effect


of Increasing Number of Missed Enoxaparin Sodium Doses
on Deep Vein Thrombosis Formation
Missed Doses

Interruption of Therapy

Abbreviation: IQR, interquartile


range.

P Value

Odds Ratio (95% CI)

P Value

1 (n = 28)

0.75 (0.08-7.00)

.80

2-4 (n = 46)

8.49 (2.57-28.04)

<.001

5-8 (n = 15)

10.13 (2.33-44.03)

.002

9-17 (n = 21)

14.73 (3.78-57.12)

<.001

2.03 (0.21-19.95)

.55

>17 (n = 9)

Upper Extremity vs Lower Extremity DVT


A total of 32 DVTs were diagnosed during the study. There
were 27 DVTs in the lower extremity and 5 DVTs in the
neck or upper extremity. In total, 92.8% of DVTs diagnosed
in the interrupted therapy group were in the lower extremity, while 25.0% of DVTs diagnosed in the uninterrupted therapy group were in the lower extremity. Three of
4 DVTs diagnosed in patients with uninterrupted therapy
were in the upper extremity or neck. All neck and upper
extremity DVTs were associated with the use of indwelling
central venous catheters or percutaneously inserted central
catheters.

Additional DVT Risk Factors


Additional univariate analyses of other common risk factors
for the development of DVT were performed and are summarized in Table 5. Patients who required ventilator support outside of the operating room or who underwent more than 1 operation during their hospitalization had a higher incidence of
DVT formation. Obesity (BMI >30), epidural catheter use, and
renal failure (creatinine clearance <30 mL/min/1.73 m2) were
not associated with increased DVT formation (to convert creatinine clearance to milliliters per second per meter squared,
multiply by 0.0167).
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367

Research Original Investigation

Doses of Enoxaparin and Increased Incidence of DVT

Table 5. Univariate Analysis Comparing Risk Factors for Deep Vein Thrombosis
%
Deep Vein Thrombosis
(n = 32)

No Deep Vein Thrombosis


(n = 170)

P Value

Interrupted enoxaparin sodium therapy

25.0

5.3

<.001

>1 Operation

59.3

40.0

.04

Risk Factor

Ventilator support

71.8

44.1

.005

BMI >30

62.5

45.0

.19

Creatinine clearance <30 mL/min/1.73 m2

9.3

18.2

.21

Epidural catheter use

6.3

1.7

.23

Abbreviation: BMI, body mass index


(calculated as weight in kilograms
divided by height in meters squared).
SI conversion factor: To convert
creatinine clearance to milliliters per
second per meter squared, multiply
by 0.0167.

Table 6. Subgroup Analysis of Trauma and General Surgery Patients


%
Variable

General Surgery

Deep vein thrombosis

15.2

17.8

.54

Missed doses

64.7

49.2

.05

>1 Operation

58.4

35.9

.001

Male sex

54.8

67.7

.06

Age 50 y

52.3

73.9

.001

BMI >30

52.1

53.7

.83

Subgroup Analysis
Subgroup analysis was performed, separating trauma and general surgery patients; the results are summarized in Table 6.
The groups had similar age distributions and obesity rates.
Trauma patients were more likely to undergo more than 1 operation during their hospitalization and were more likely to be
younger than 50 years than general surgery patients. Deep vein
thrombosis occurred at a similar rate in the 2 groups, as did
missed doses.

Multivariate Analysis
A bivariate logistic regression was then performed, including
commonly accepted risk factors for DVT and those we found
to be associated with DVT formation on univariate analysis
(Table 7). Only interrupted enoxaparin therapy and age 50 years
or older were independent risk factors for DVT. Trauma, male
sex, obesity, multiple operations, and ventilator support were
not found to be independent risk factors.

Discussion
In this study, we hypothesized that interruption of pharmacologic prophylaxis after it was initiated would lead to an increase in the diagnosis of DVT. Interruption of prophylactic anticoagulation is common in patients admitted after major
trauma and in patients undergoing major surgery. More than
half of our patients had at least 1 dose missed during their hospitalization, with most of these patients missing more than 1
dose. When multivariate analysis was performed, interruption of therapy was a strong independent risk factor for the development of DVT.
Coagulopathy in patients following trauma and major surgery remains incompletely characterized. These patients have
significant disruptions in the normal homeostatic balance of
368

P Value

Trauma

procoagulants and anticoagulants.12-14 The introduction of


pharmacologic anticoagulation further contributes to an already deranged system in ways that are only partially understood. It has been suggested that initiation and subsequent interruption of pharmacologic anticoagulation may exacerbate
a hypercoagulable state following trauma.11,15 A recent study11
performed in patients with traumatic brain injury demonstrated higher VTE rates in patients who had interrupted
therapy compared with patients who had prophylaxis withheld until all expected surgical procedures were completed.
Our data regarding catheter-associated DVT are also compelling. Of 4 DVTs diagnosed in the patients who underwent
uninterrupted therapy, 3 were provoked by the use of an indwelling catheter (central venous catheter or percutaneously
inserted central catheter). This leaves a single DVT that was
not caused by a catheter when enoxaparin was not interrupted. The patient had undergone total hip arthroplasty and
developed ipsilateral DVT.
The formation of DVT does not occur in a vacuum, and a
significant body of literature is dedicated to attempts at isolating risk factors for DVT. Variable characteristics between patients with vs without DVT herein were similar to risk factors
acknowledged by several large studies.16-18 These included multiple operations, age 50 years or older, and ventilator support
required outside of the operating room. In addition, the patients with DVT had a longer overall hospital length of stay and
a longer duration of enoxaparin therapy. We also found that
men had a higher likelihood of DVT diagnosis, which is likely
due to a type I statistical error owing to our small sample size
because this has not been found in previous larger studies.
Multivariate analysis was performed to attempt to isolate
the effect of interruption of prophylaxis on DVT formation. We
found age 50 years or older and interrupted enoxaparin therapy
to be the only independent risk factors for DVT formation. This
study argues against the hypothesis that it is not the missed

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Abbreviation: BMI, body mass index


(calculated as weight in kilograms
divided by height in meters squared).

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Doses of Enoxaparin and Increased Incidence of DVT

Original Investigation Research

Table 7. Bivariate Logistic Regression Comparing Risk Factors


for Deep Vein Thrombosis
P Value

Risk Factor

Odds Ratio (95% CI)

Missed doses

5.34 (1.60-17.81)

.006

Ventilator support

2.31 (0.88-6.05)

.09

>1 Operation

1.25 (0.48-3.25)

.64

Trauma

1.08 (0.39-2.99)

.89

Epidural catheter use

2.07 (0.29-14.99)

.47

Male sex

2.06 (0.78-5.60)

.16

Creatinine clearance <30 mLmin1.73 m2

0.35 (0.09-1.41)

.14

Age 50 y

3.12 (1.14-8.56)

.03

BMI >30

1.43 (0.58-3.53)

.44

Twice-daily dosing

0.94 (0.34-2.60)

.90

Abbreviation: BMI, body mass index (calculated as weight in kilograms divided


by height in meters squared).
SI conversion factor: To convert creatinine clearance to milliliters per second per
meter squared, multiply by 0.0167.

doses themselves but rather the reasons behind the missed


doses (eg, for the operating room) that lead to increased incidence of DVT.
Pending invasive procedures were the most common documented reason for withholding doses. However, we found that
surprising numbers of doses were withheld without a specified cause. Other reasons for missed doses included patient refusal, epidural catheter removal, nursing and pharmacy errors, and the patient being absent from the room. Doses
withheld for ambiguous reasons decreased during the study
because implementation of the electronic medical record at our
institution required reasons to be specified. Because of the significant findings of this study, missed doses of enoxaparin now
represent a quality improvement measure at our hospital, and
we have educated surgeons about the adverse consequences

ARTICLE INFORMATION
Accepted for Publication: June 28, 2013.
Published Online: February 26, 2014.
doi:10.1001/jamasurg.2013.3963.

of missing doses. These interventions have already resulted


in a reduced percentage of doses withheld.
Our study has several acknowledged limitations. First,
while the small sample size suggests the possibility of a type I
error, the study was adequately powered. Second, many patients received short courses of anticoagulation therapy. Although we attempted to enroll severely ill patients (as evidenced by the mean APACHE II score of 14), a significant
number of patients underwent 5 days of therapy or less. Third,
despite a rigorous screening protocol, there was variance in
screening between the trauma patients and the general surgery patients on the ward. Trauma patients were screened on
a weekly basis, while general surgery patients were screened
based on symptoms. This could have introduced surveillance
bias, as has been noted in other studies.11,19

Conclusions
Although it is generally agreed by clinicians that pharmacologic prophylaxis should begin as soon as possible based on
the physicians assessment of a patients bleeding risk, the decision to withhold a dose of enoxaparin is often undertaken
without comprehensively assessing the consequences. While
we do not recommend continuing anticoagulation during highrisk operations such as intracranial or spinal procedures, the
decision to withhold prophylaxis before multiple low-risk operations should not be taken lightly. In addition, optimization of systems to eliminate unnecessary missed doses is imperative. Through nursing and patient education, doses missed
because of nursing errors or patient refusal should be eradicated. Missed doses are the only identified risk factor for DVT
that can be ameliorated by physicians, and efforts to minimize interrupted enoxaparin prophylaxis in patients at risk for
DVT should be optimized.

Previous Presentation: This study was presented


at the Pacific Coast Surgical Association 84th
Annual Meeting; February 17, 2013; Kauai, Hawaii.
REFERENCES

Author Contributions: Dr Louis had full access to


all the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Cho, Underwood,
Differding, Watters, Schreiber.
Acquisition of data: Louis, Sato, Geraci, Anderson,
Cho, Van, Barton, Riha, Underwood, Differding,
Watters.
Drafting of the manuscript: Louis.
Critical revision of the manuscript for important
intellectual content: Schreiber.
Statistical analysis: Louis.
Administrative, technical, or material support: Louis,
Sato, Geraci, Anderson, Cho, Van, Barton, Riha,
Underwood, Differding, Watters.
Study supervision: Underwood, Differding,
Schreiber.
Conflict of Interest Disclosures: None reported.

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Invited Commentary

Order and Execution of DVT Prophylaxis


The Best-Laid Plans of Mice and Men
Joseph M. Galante, MD

Robert Burns wrote, The best-laid plans of mice and men/


Often go awry. In keeping with this theme, Louis and colleagues in Correlation of Missed Doses of Enoxaparin With
Increased Incidence of Deep Vein Thrombosis in Trauma and
General Surgery Patients1 examined whether their intentions to provide deep vein
Related article page 365
thrombosis (DVT) prophylaxis to surgery patients were being fulfilled. The authors prospectively collected data on 202 trauma and emergency surgery patients who were started on a regimen of enoxaparin
sodium between 2007 and 2012. Duplex ultrasonography of the
upper and lower extremities and neck veins revealed a DVT in
15.8%. Fifty-nine percent of the patients with DVT had missed
a dose of enoxaparin, with most missing 1 to 4 doses. In 4 patients who developed DVT with uninterrupted enoxaparin
therapy, 3 cases were associated with indwelling catheters in the
neck and upper extremities. Multivariate analysis, accounting
for appropriate risk factors, showed that only age 50 years or
older and a missed dose of enoxaparin were associated with an
increased risk for DVT. Although documentation was poor, common reasons for missed doses were pending procedures, the absence of the patient from the room, and epidural catheter use;
however, many patients had no reason documented.
Deep vein thrombosis prophylaxis is a complex subject,
particularly in the trauma and emergency surgery population. Systematic reviews and prospective trials have been conducted to identify which drug is best for prophylaxis2 and
ARTICLE INFORMATION

Medical Center, University of California, 2315


Stockton Blvd, Sacramento, CA 95817 (Joseph
.galante@ucdmc.ucdavis.edu).

Author Affiliation: Division of Trauma and


Emergency Surgery, Davis Medical Center,
University of California, Sacramento.
Corresponding Author: Joseph M. Galante, MD,
Division of Trauma and Emergency Surgery, Davis

370

which dose of drug produces therapeutic anti-Xa levels.3 Timing of administration has been addressed in traumatic brain
injury,4 and recommendations have been made for hip fracture surgery.5 As the article in this issue of the journal shows,
these discussions are moot if the patient does not receive the
prescribed medication.
Missed doses of prescribed medications are significant not
only for patients but also for health systems, particularly in an
era of public reporting and the linkage of reimbursements to
performance measures. The authors must be commended for
asking a simple question: are my patients really receiving what
I intended them to receive? The answer to the question is disturbing and requires a complex solution. With the publication of the Institute of Medicine reports, To Err Is Human6
and Crossing the Quality Chasm,7 hospital and physician practices have attempted to reduce and eliminate medical errors
through patient safety initiatives. Such enterprises include electronic medical records, computer order entry, and increased
evidence-based recommendations. Despite orders and pharmacy checks in accord with best practices and information
technology oversight, individual patients are still not receiving intended care. The persistence of missed medication doses
should prompt continued review of mechanisms used to deliver care at the individual patients bedside. We have invested millions, if not billions, of dollars into systems to ensure that physicians best-laid plans for patients are carried out,
but it seems, as Burns wrote, that these plans Often go awry/
And leave us nothing but grief and pain/For promised joy!

Published Online: February 26, 2014.


doi:10.1001/jamasurg.2013.4002.

REFERENCES
1. Louis SG, Sato M, Geraci T, et al. Correlation of
missed doses of enoxaparin with increased
incidence of deep vein thrombosis in trauma and
general surgery patients [published online February

Conflict of Interest Disclosures: None reported.

JAMA Surgery April 2014 Volume 149, Number 4

Copyright 2014 American Medical Association. All rights reserved.

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