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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - November 8, 2013
Cognitive testing of older clinicians prior to recredentialing.
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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - potential vulnerabilities.( 14 ) Usability testing can aid in the improved design of pump labels and other cognitive
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - Given the cognitive and efficiency disadvantages of systems that require radiologists to look away from
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - coping strategies such as problem simplification (the central line should stay in), missing ad hoc cognitive
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - questions, but this finding was attributed to the language barrier, as she had no reported history of cognitive
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psnet.ahrq.gov/toolkits
March 01, 2025 - Pharmacy
(10)
Error Types
Active Errors
(37)
Cognitive
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - assessment.( 1 ) Such assessments should be conducted on a regular basis to evaluate and monitor patients' cognitive
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Cognitive systems at the point of care: the CREDO program. J Biomed Inform. 2017;68:83-95.
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - When, as in this case, cognitive, cultural, or other barriers prevent them from being able to provide
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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - is essential to provide person-centered care for all older adults, particularly those patients with cognitive
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - Cognitive-behavioral interventions to reduce suicide behavior: a
systematic review and meta-analysis
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - Appreciate the cognitive steps to determine prognosis in elderly patients.
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - March 25, 2017
Advancing the next generation of handover research and practice with cognitive
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - 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/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - to clinicians' tendency to misattribute symptoms of individuals with learning disabilities to their cognitive
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - One Dose, Fifty Pills
November 1, 2005
Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills
The Case
A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis.
When the initial diagnostic studies failed to provide …
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - cultural or communication barriers, or implicit bias related to the patient's age or post-anesthesia cognitive
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - Health Care Transitions and Incident Feeding Tube Insertion Among Persons with Advanced Cognitive Impairment