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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Pharmacy
(4)
Error Types
Active Errors
(7)
Cognitive
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - environments for nurses, which may augment patient outcomes by enhancing teamwork and reducing time pressure, cognitive
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psnet.ahrq.gov/node/33747/psn-pdf
March 01, 2013 - 20,000 participants) confirmed theory-based predictions that
feedback, repetition, range of difficulty, cognitive
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Does this patient lack the cognitive ability to make relevant decisions?
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psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
January 01, 2020 - event
9
9
Suicide Risk Factors (2)
Suicide exposure (peer or celebrity)
Access to lethal means
Cognitive
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Climate as a social-cognitive construction of supervisory safety practices: scripts as
proxy of behavior
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - surgical plan in the face of a difficult procedure is a common variant of perioperative fixation error, a cognitive … No simple fix for fixation errors: cognitive processes and their clinical applications.
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - making sure that competing hypotheses can be
reasonably excluded.1
13
Diagnostic Failure (2)
• Cognitive … hyponatremia, and hypotension.
16
Diagnostic Failure: The Missing Bedside Examination (3)
• Beyond the cognitive
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psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
November 02, 2016 - the course of clinical care.( 10 ) Diagnostic performance examines both the individual performance (cognitive … diagnostic performance will not only require a closer look at clinical processes, but also providers' cognitive
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - healthcare
system
System-related errors, which include technological or organizational barriers
Cognitive … Because of the cognitive error made in this case, the PCP involved would benefit from feedback and further
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - They're all tasks for which cognitive and task variables suggest that they are at risk of disruption … Or is it worse if it's something that you have to think very hard about, with a high cognitive load associated … If you're performing a high cognitive load task, then you are at very much risk of disruption. … October 4, 2023
Education initiatives in cognitive debiasing to improve diagnostic accuracy
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - Adverse Events, Near Misses, and Errors
Citation Text:
Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - medication to a patient), breaking it down to its component tasks, and
then assessing the physical and cognitive
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psnet.ahrq.gov/node/866395/psn-pdf
July 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/node/49581/psn-pdf
March 21, 2009 - health care practitioners; and (iii) a push for efficiency over safety that
decreases the time for cognitive
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - driven in part by the “technological
imperative”(14) is dangerous, particularly for patients whose cognitive
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psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - includes, as a minimum, a general examination, digital anorectal examination (3,9), and assessment of
cognitive
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psnet.ahrq.gov/topics-0
March 03, 2025 - this topic
Active Errors Go to this topic
Cognitive
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Understanding the cognitive work of nursing in the acute care
environment.
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - such as these, each of which may be independently insufficient to cause harm.(5)
As Leape points out, cognitive