Pulmonary Embolism Audit

This project audits the quality, timeliness, documentation and reliability of suspected and confirmed pulmonary embolism care. It reviews whether patients are assessed using an agreed pathway with documented clinical probability, whether D-dimer and imaging decisions and results are recorded, whether interim and definitive anticoagulation is safe and considers bleeding risk, renal function, weight, pregnancy and cancer status, whether confirmed PE is risk-stratified and escalated when high risk, whether outpatient or ambulatory management is considered where appropriate, and whether counselling, safety-netting, anticoagulation duration, discharge communication and follow-up are documented.

• Emergency, acute medicine, respiratory, SDEC and ambulatory care teams
• Anticoagulation, pharmacy and thrombosis teams
• Radiology and diagnostic pathway teams; critical care and outreach where high-risk PE is escalated
• QI leads, governance teams, supervisors and educators

• Measure whether suspected PE is assessed and investigated according to an agreed local pathway
• Assess anticoagulation safety, including bleeding risk and dosing modifiers
• Review risk stratification, escalation and outpatient/ambulatory eligibility decisions
• Identify variation across clinical areas, care settings, imaging types and case mix
• Generate governance-ready and ARCP-ready evidence and a re-audit cycle

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised context (age band, sex/gender recorded, care setting, assessment context, imaging type)
• Clinical area / location and optional specialty / service
• Nineteen pulmonary embolism criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports, but does not replace, clinical judgement. Follow local PE, imaging, anticoagulation and escalation policy, formulary and specialist advice.
• Imaging modality, risk scores, anticoagulant choice, timing thresholds, outpatient eligibility and follow-up arrangements remain locally configurable and are not national standards.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Patient SafetyDiagnostic Delay: Understanding and Mitigating a Critical Patient Safety RiskDiagnostic delay is a significant patient safety concern across all healthcare settings. This guide explains why timely diagnosis is crucial, details the common factors contributing to delays, and provides actionable strategies for healthcare professionals and teams to mitigate these risks.
• Patient SafetyMedicines Safety: A Systems Approach to Reducing HarmThis guide moves beyond individual error, explaining how a systems-based approach can fundamentally improve medicines safety across the NHS and reduce patient harm by addressing underlying contributing factors.
• Quality ImprovementHow Many PDSA Cycles Does a Quality Improvement Project Need?This guide explains the iterative nature of PDSA cycles and offers practical advice for determining the appropriate number of cycles needed for effective quality improvement in NHS settings.
• Quality ImprovementPlanning Effective PDSA Cycles for Quality ImprovementThis guide provides a practical, step-by-step approach to planning effective Plan-Do-Study-Act (PDSA) cycles for quality improvement initiatives within the NHS, focusing on robust design and learning. It covers essential considerations from defining your aim to anticipating challenges, helping teams systematically test changes.