Table 3.
Patient Safety Issues and Special Populations Addressed by the AHRQ-Funded Patient Safety Projects
| Number of Issues by Type of Grant | ||||
|---|---|---|---|---|
| FY 2000–2001 | Challenge | Health IT | PIPS | |
| Patient safety issue | ||||
| Medication ordering/administration | 29 | 7 | 60 | 9 |
| Noscomial infections | 4 | 2 | 1 | |
| Falls/pressure ulcers | 6 | 2 | ||
| Nurse staffing | 12 | 2 | ||
| Provider fatigue, working conditions | 16 | 2 | 1 | |
| Surgical/invasive procedure errors | 11 | 2 | 1 | |
| Diagnostic/treatment errors | 18 | 37 | 3 | |
| Equipment/device failure | 5 | 1 | ||
| Ordering/administering blood | 1 | |||
| Care procedures and coordination* | 2 | 60 | 3 | |
| Wrong patient/procedure/test | 1 | |||
| General patient safety | 40 | 3 | 6 | |
| Handoffs | 2 | 2 | 62 | 3 |
| Other issues | 4 | 2 | ||
| Total number of issues studied | 147 | 25 | 230 | 20 |
| Average number per project | 1.8 | 1.9 | 2.2 | 1.2 |
| Special populations | ||||
| Elderly | 17 | 3 | 17 | 4 |
| Minority populations | 17 | 1 | 16 | 3 |
| Low income | 15 | 1 | 25 | 2 |
| Health vulnerable | 10 | 4 | 34 | 3 |
| Other vulnerable | 5 | 1 | 13 | 1 |
*
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.