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www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
January 01, 2025 - on issues that lie at the intersection of diagnostic error and fields such as clinical
informatics, cognitive … Diagnostic errors reflect both system-level failings and cognitive failings.(2) Among the most common … cognitive origins of diagnostic errors are failures to gather and synthesize the available information … For example, Croskerry has
proposed that cognitive training methods might decrease the rate of diagnostic … The importance of cognitive errors in diagnosis and strategies to minimize them.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_preeclampsia.docx
May 01, 2017 - .
· Demonstrate the efficient use of checklists, protocols, or similar cognitive aids for evaluation … During the simulation, participants are encouraged to practice the use of protocols, checklists, or cognitive … call team huddle.
· Team initiates appropriate clinical response per any protocols, checklists, or cognitive … Team initiates appropriate clinical response per any protocols, checklists, or cognitive aids. … Team initiates appropriate clinical response per any protocols, checklists, or cognitive aids.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-4.html
March 01, 2022 - These largely relate to clinical reasoning and ways to mitigate the harmful effects of clinicians' cognitive … Finally, the importance of reflection and cognitive humility is emphasized. … Avoiding common cognitive pitfalls. 52 Many cognitive errors arise from unconscious tendencies that
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/slides-healthcare-safer-by-design.pdf
August 20, 2024 - Continuity of care Team Care
Stable
relationships
Effective EHR
High reliability
systems
Optimize cognitive … Cognitive Load and Diagnostic Accuracy
“Diagnostic reasoning has historically been treated
as intrinsic … However, there is now growing
recognition that cognition is complex and affected by
context, cognitive … All rights reserved.18
Everyday examples, obstacles, and cognitive overload
I am frequently
interrupted … Slide Number 15
Drivers of Burnout – how we work
Slide Number 17
Everyday examples, obstacles, and cognitive
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiif.html
June 01, 2010 - Adults with developmental disabilities, nonelderly adults with physical disabilities, elders with cognitive … States Currently Using: Maine
Psychometric Testing: Limited cognitive testing, some modifications … The tool underwent iterative rounds of cognitive testing before field testing in 2004. … and Other Services, and Timeliness
Populations: Elders with physical disabilities and elders with cognitive … and Welfare, Unmet Need, and Quality of Life
Populations: Elders with physical disabilities and cognitive
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reports.html
November 01, 2017 - Have no cognitive impairment? … existing condition
Resident must have at least three of four high-risk existing conditions:
Severe cognitive … Fall High-Risk Existing Conditions
High-Risk Existing Condition
Definition
Severe cognitive … score is 0-7 or problem making self understood (B0700), short-term memory problem (C0700), or impaired cognitive … Each of these high-risk factors can be linked to a high-risk existing condition: mental, cognitive impairment
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
September 01, 2021 - safety threats such as having the proper tubing for blood transfusion available in all
rooms) and cognitive … Errors Significant evidence exists to suggest that
providers may be affected by underlying
cognitive … Determine impact of various cognitive
errors (e.g., implicit bias, anchoring,
confirmation, knowledge … Treatment
Standardizing treatment can reduce
cognitive error. … ‘More than words’ - interpersonal communication, cognitive bias
and diagnostic errors.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-3.html
September 01, 2023 - Since the cognitive component of diagnostic reasoning is often invisible or intangible, some may ask
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html
July 01, 2023 - Cognitive aids and checklists that list indications, contraindications, and maternal and fetal criteria … Use cognitive aids such as checklists, algorithms, or protocols to guide a systematic approach to management … Cognitive aids such as checklists, algorithms, or protocols may improve team response and management … Use of cognitive aids (e.g., checklists, protocols) for guiding clinical management and documentation
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www.ahrq.gov/sites/default/files/2024-01/lapane-report.pdf
January 01, 2024 - Topics covered in the MDS include cognitive
function, physical functioning, continence, psychosocial … The MDS Cognitive Performance Scale (CPS) is a categorical measure of
cognition using these MDS items … and several items that indirectly evaluate cognitive function
(i.e., comatose state, total dependent … Designed to assign residents
into easily understood cognitive performance categories, the CPS score … MDS cognitive performance scale. J Gerontol 1994;
49:M174-M182.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
April 07, 2008 - Broadly titled, these focus areas are
(1) cognitive simulation, (2) informatics, (3) “smart image,” … Cognitive Simulation
As new surgical technologies and techniques emerge, patients are often torn between … In particular,
cognitive simulation can provide clinicians with the opportunity to rehearse and explore … Given the effect the development of a cognitive simulator can make in regard to training and
patient … This multivariate cognitive simulation possesses the ability to grow, change, and
experience biologic
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www.ahrq.gov/patient-safety/resources/simulation-issue-brief3.html
July 01, 2024 - More than half (6 of 11) reported latent safety threats involved a cognitive aid. … Hazards embedded in the cognitive aids included recommending an incorrect dose or route for epinephrine
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www.ahrq.gov/sites/default/files/2025-03/wears-perry-report.pdf
January 01, 2025 - EDs use status boards to support a variety of cognitive and coordinative
functions. … Mapping cognitive properties of the status board onto patient safety. … A
comprehensive description of the status board as a cognitive and artefact was
developed with … Cognitive properties of a whiteboard: a case
study in a trauma centre. … The Master Schedule: How Cognitive Artifacts Affect Distributed
Cognition in Acute Care.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking4.html
September 01, 2022 - intuitive and uses information provided at the point of care, and it would not add substantial time or cognitive
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-3.html
September 01, 2021 - 38–41 Additional research could explore how simulation can also serve as a means of mitigating both cognitive … latent safety threats such as having the proper tubing for blood transfusion available in all rooms) and cognitive
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-7.html
September 01, 2020 - A cognitive forcing tool to mitigate cognitive bias – a randomised control trial.
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www.ahrq.gov/cahps/surveys-guidance/maternal-health/index.html
March 01, 2025 - more complex deliveries, and those who had experienced first-time childbirth or prior births. 2025 Cognitive … testing : In 2025, the team will conduct cognitive interviews in both English and Spanish and revise
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0217-section-5-table-5.pdf
April 01, 2014 - Assessment depends on the chronologic age,
developmental stage, functional status, cognitive
ability … The
choice of tool will depend on the age, cognitive
ability, and emotional state. … of pain intensity that can be
quickly completed, accounting for the child’s
development stage and cognitive
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www.ahrq.gov/talkingquality/translate/labels/explain-score.html
March 01, 2016 - Switching directions can be confusing and create a cognitive burden on users of the information. [1]
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
May 01, 2017 - Electronic
Fetal Monitoring
6
Safe EFM Tool
Purpose
Who should use
How to use
Key safety elements
Sample cognitive … Perinatal Care
Electronic
Fetal Monitoring
11
Key Safety Elements: Create Independent Checks
Providing cognitive … aids for standard EFM terminology and interpretation at the point of care
A sample cognitive aid using … and communication related to—
Situational awareness;
Ability to get additional help quickly;
Use of cognitive