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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - alternative diagnosis rather than pursue a test for a diagnosis already in doubt
Be aware of common cognitive
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - especially in patients who may not be able to communicate effectively with the nursing staff due to cognitive
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - often the product of a series of errors (both human and technical), and why it is important to mitigate cognitive
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33720/psn-pdf
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
In Conversation With… Eduardo Salas, PhD . PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
Editor's note: Eduardo Salas, PhD, is a University Trustee Chair and Pegasus Professor of Psychology at
the University of Ce…
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - Annual Perspective
Communication During Transitions of Care
Ayse P. Gurses; Sarah Mossburg; Zoe Sousane
| March 27, 2024
View more articles from the same authors.
Citation Text:
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Duplicate Insulin Order
Citation Text:
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - Unplanned weight loss, increased incontinence and decreased cognitive function has also been reported
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - Unplanned weight loss, increased incontinence and decreased cognitive function has also been reported
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - • In many EHRs, such alerts are turned off or made passive to avoid "alert fatigue,"
which is a cognitive
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - The accepted term for a comprehensive and coherent cognitive
representation of the current clinical
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - For example, a patient with cognitive impairment requires different interventions
than a patient at
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - Emergency Departments
Health Care Providers
Infectious Diseases
Clinical Misdiagnosis
Cognitive
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Hospitals
Health Care Executives and Administrators
Nurse Care
Indwelling Tubes and Catheters
Cognitive
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - potential to directly cause an ADE (e.g., benzodiazepines are PIMs for older adults and can directly cause cognitive
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - such as communication issues, fatigue, distractions, workflow inefficiencies, equipment malfunctions, cognitive
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - Mindset is a
cognitive orientation constituted through how we go about talking to each other.
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psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
May 31, 2023 - Saria, PhD
July 1, 2019
Mind the overlap: how system problems contribute to cognitive
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man…