Table 2.
Patient Safety Issues and Special Populations Addressed by the AHRQ-Funded Patient Safety Projects
| Number of Issues by Type of Grant |
|||
|---|---|---|---|
| Original Grants | Challenge Implementation | PIPS | |
| Patient safety issue | |||
| Medication ordering/administration | 15 | 4 | 9 |
| Nosocomial infections | 3 | 2 | 1 |
| Falls/pressure ulcers | 3 | ||
| Nurse staffing | 1 | ||
| Provider fatigue, working conditions | 3 | 1 | |
| Surgical/invasive procedure errors | 6 | 1 | |
| Diagnostic/treatment errors | 9 | 3 | |
| Equipment/device failure | 1 | 1 | |
| Ordering/administering blood | 1 | 1 | |
| Care procedures and coordination* | 1 | 3 | |
| Wrong patient/procedure/test | |||
| General patient safety | 25 | 2 | |
| Hand offs | 1 | 3 | |
| Other issues | 3 | ||
| Total number of issues studied | 70 | 13 | 20 |
| Average number per project | 1.7 | 1.9 | 1.2 |
|
Projects That Targeted Special Populations |
|||
| Special populations | |||
| Elderly | 4 | 3 | 4 |
| Minority populations | 10 | 1 | 3 |
| Low income | 7 | 1 | 2 |
| Health vulnerable | 3 | 4 | 3 |
| Other vulnerable | 2 | 1 | 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; PIPS, Partnerships in Patient Safety projects.