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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - to expect busy clinicians to
mechanistically review all their medication orders, and then to change 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
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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/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Patient Safety Challenges of this Case RCFEs commonly care for older residents with cognitive impairment
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psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-0
May 26, 2010 - Toolkit
AHRQ Health Literacy Universal Precautions Toolkit. 2nd edition.
Citation Text:
Brega AG, Barnard J, Mabachi NM, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2015. AHRQ Publication No. 15-0023-EF.
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psnet.ahrq.gov/issue/surveys-patient-safety-culturetm-sopsr-ambulatory-surgery-center-survey-2021-user-database
June 01, 2022 - Book/Report
Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey: 2021 User Database Report.
Citation Text:
Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.
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psnet.ahrq.gov/issue/ahrq-epc-program-grand-rounds-making-healthcare-safer
December 16, 2015 - United States Meeting/Conference
AHRQ EPC Program Grand Rounds - Making Healthcare Safer.
Citation Text:
Agency for Healthcare Research and Quality Evidence-based Practice Center and the Scientific Resource Center. April 29, 2024, 12:00-2:00 PM (eastern)
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psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the
Division of Biomedical and …
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/periodic-issue/periodic-issue-306
August 25, 2021 - The authors highlight cognitive and systems factors that influenced this diagnostic error.
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psnet.ahrq.gov/periodic-issue/periodic-issue-375
December 14, 2022 - The majority of issues were a related to providers’ cognitive processing, revealing an important area
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psnet.ahrq.gov/periodic-issue/periodic-issue-397
June 28, 2023 - overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive
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psnet.ahrq.gov/periodic-issue/periodic-issue-393
June 28, 2023 - Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology.
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - – Psychotherapies may include supportive, cognitive, and dialectical behavioral therapies, but
their
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - utilization, comorbidities,
insurance, and a variable to capture language barrier, poor health literacy, or cognitive
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - Strategies to prevent falls and fractures in hospitals and care
homes and effect of cognitive impairment
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - to safely use prescribed medications, as they are disproportionately affected by
limited literacy, cognitive
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - words, why are sound-alike drugs stored in close proximity and why haven't steps
been taken to reduce cognitive
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Basic assumptions and lessons distilled from the cognitive systems engineering literature (11-14) are
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - elements.( 14 ) Designing for users means both physical performance (e.g., programming a technology) and cognitive