VTE is a leading cause of preventable hospital death. Effective prophylaxis requires more than "checking the box"; it demands tailoring orders to patient physiology. For medical patients with renal failure, switch from Enoxaparin to Heparin 5,000 units TID. Trauma patients often require aggressive 40 mg BID dosing due to high metabolism, while neuro-trauma requires 30 mg BID. For obesity, use weight-based dosing (0.5 mg/kg) and consider Anti-Xa monitoring to ensure safety.