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

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• NICE

  NG158: Venous thromboembolic diseases — diagnosis, management and thrombophilia testing(opens the original source in a new tab)

  National guideline covering suspected PE assessment, diagnostic testing, anticoagulation and follow-up.

• NICE

  QS201: Venous thromboembolism in adults(opens the original source in a new tab)

  Quality standard including follow-up for people having outpatient treatment for suspected or confirmed low-risk PE.

• British Thoracic Society

  Guideline for the initial outpatient management of pulmonary embolism(opens the original source in a new tab)

  National specialty guideline on outpatient / ambulatory management of low-risk PE.

• British Thoracic Society

  Quality standards for outpatient management of pulmonary embolism(opens the original source in a new tab)

  Suggested source requiring user review — confirm the current edition used locally.

• MHRA

  Anticoagulant safety advice and Drug Safety Update(opens the original source in a new tab)

  Suggested source requiring user review — confirm which anticoagulation safety advice applies to the project scope.

• 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.
• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.
• Patient SafetyHow to Select a Patient Safety Quality Improvement ProjectThis guide helps NHS teams identify and select patient safety quality improvement (QI) projects that are impactful, achievable, and aligned with organisational and national priorities. Learn how to move from identifying concerns to choosing a focused and measurable project.