Case presentation : A 79-year-old woman was noted by staff at her skilled nursing facility to have increasing shortness of breath during the previous 24 to 48 hours. She had been receiving daily physical therapy, occupational therapy, and 6 prescription medications to manage underlying congestive heart failure with preserved systolic function. The woman was hospitalized. After being transferred to the emergency department, she underwent further workup, which showed no pulmonary embolism on chest CT scan. The chest x-ray, however, revealed a new right lobar infiltrate and consolidation, which are consistent with pneumonia. On examination, she was alert, with a respiratory rate of 24 per minute, heart rate of 96 bpm, blood pressure of 154/76 mm Hg, temperature of 38°C, distended neck veins, right lower lung zone posterior musical rales, regular heart rhythm, normal S1, single S2, and grade II/VI systolic murmur at the left lower sternal border. The diagnosis of pneumonia was made, and levofloxacin was initiated in the emergency department. Specific evaluation of her medical regimen, including furosemide, potassium chloride, metoprolol, candesartan, simvastatin, and baby aspirin, was recommended. Prevention of venous thromboembolism has been neglected in hospitalized patients with medical illnesses such as congestive heart failure, chronic lung disease, cancer, and infectious diseases. In the Medical Intensive Care Unit (MICU) at Brigham and Women’s Hospital, we found a combination of omitted and ineffective prophylaxis. When we performed venous ultrasound examinations on 100 patients admitted to the MICU with an anticipated stay of >48 hours, we detected deep vein thrombosis (DVT) in 33%.1 Almost 50% of the patients with DVT …