-
psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - Well
practiced routines such as phlebotomy, although having little cognitive error potential, are often
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Broadening our discussion to error theory
in general, errors related to knowledge-based cognitive behaviors
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - provide effective
analgesia, they may exacerbate symptoms already prevalent in dialysis patients such as cognitive
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - miss in this case, but it does
not guarantee safety.(12) Repetitive, routine tasks are subject to cognitive
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psnet.ahrq.gov/node/49815/psn-pdf
December 01, 2017 - bottles), only
36.3% of patients were able to complete the form without error.(3) Poor health literacy, cognitive
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - importance of imaging in patients with high-risk abdominal pain, and how to mitigate the influence of cognitive
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - organization, all M&M reviews include the core principles of the RIC—namely, review of systems, team, and cognitive
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psnet.ahrq.gov/training-catalog
June 01, 2025 - : Previously-recorded events that discusses strategies to avoid medical mistakes, how to recognize cognitive
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Understanding the cognitive work of nursing in the acute care environment.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
March 01, 2014 - to patients
22
22
Take-Home Points
As a professional responsibility, providers should commit to cognitive
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - as these, each of which may be independently insufficient to cause harm.( 5 ) As Leape points out, cognitive
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - importance of imaging in patients with high-risk abdominal pain, and how to mitigate the influence of cognitive
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psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
June 15, 2024 - medication nonadherence into patient-related factors (i.e. disease-state knowledge, health literacy, cognitive
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psnet.ahrq.gov/web-mm/transition-nowhere
March 21, 2009 - Diagnostic Misstep
January 1, 2019
WebM&M Cases
Cognitive
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psnet.ahrq.gov/perspective/patient-safety-primary-care
January 31, 2020 - Cognitive and system factors contributing to diagnostic errors in radiology.
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - Health Care Transitions and
Incident Feeding Tube Insertion Among Persons with Advanced Cognitive Impairment
-
psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. … The clearer that is, the less cognitive burden there is. … They are distraught, they may be sleep deprived or have cognitive processing problems as part of a mental
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psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
March 25, 2025 - The clearer that is, the less cognitive burden there is. … They are distraught, they may be sleep deprived or have cognitive processing problems as part of a mental … Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis.