Table 2.

Patient Safety Issues Addressed by AHRQ-Funded Projects for Epidemiology or Root Cause Analysis

	Number of Issues by Type of Grant
Patient Safety Issue	FY 2000–2001	Challenge	Health IT	PIPS
Medication ordering/administration	21	5	2	1
Nosocomial infections	3
Falls, pressure ulcers, restraint related	3
Nurse staffing	9	1
Provider fatigue/working conditions	12
Surgical/invasive procedure errors	5	2
Diagnostic or treatment errors	11
Equipment/device failure	2	2
Ordering/administering blood	1
Care procedures and coordination*	1	1
Wrong patient/procedure/test
General patient safety	34	1	2
Handoffs
Other issues	4	2
Total number of issues studied	106	14	4	1
Number of projects studying epidemiology or root cause	56	8	3	1
Average number per project	1.9	1.8	1.3	1.0

^*Care procedures and coordination include errors in the admitting process, such as applying the wrong patient identification bracelet, misplaced documentation such as “lost” medical records, failure to notify patients of a positive test result, failure to register a patient in the emergency department resulting in delayed care and adverse outcome, etc.

AHRQ, Agency for Healthcare Research and Quality; FY, fiscal year; IT, information technology; PIPS, Partnerships in Patient Safety projects.