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www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
January 01, 2024 - slip, a failure in cognitive execution). … And, it is information that is central to the success of many cognitive
tasks47 that support diagnosis … The reason information is so central is that, for a
range of cognitive tasks, such as decision-making … A cognitive task analysis of information
management strategies in a computerized provider order entry … Joint Cognitive Systems: Foundations of Cognitive Systems Engineering.
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
January 01, 2017 - Affective Bias
Cognitive Bias
What interventions work?
Decision support ?
Second opinions ? … Patient’s Clinical Course
SYSTEM
Me
Communication,
coordination, training,
policies, procedures
Cognitive
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-spanishitems.pdf
June 02, 2025 - Translation, Analysis of Findings, and Recommended Changes
The two bilingual translators conducted three cognitive … positions were interviewed.
3) Final Review and Decisions
The Westat translation team analyzed the cognitive
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship4.html
August 01, 2024 - While the failure to correctly interpret a diagnostic test result may reflect knowledge gaps or cognitive
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www.ahrq.gov/research/publications/search.html?page=3
September 01, 2022 - Search Publications
The Agency for Healthcare Research and Quality (AHRQ)'s publications offer practical information to help a variety of health care organizations, providers, and others make care safer in all health care settings. 31 - 40 of 191 Publications displayed
Find Publications by Keyword or Topi…
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2022.pdf
March 01, 2023 - Federal Interagency Workgroup--Diagnostic Safety: November Meeting Summary
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
November Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested that “AHRQ …
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www.ahrq.gov/action-alliance/competencies-affinity-group/index.html
May 01, 2025 - Organizational Safety Knowledge and Behaviors Appropriate Standardization Care Transitions/Handoff Cognitive
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www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
January 01, 2025 - Preliminary analysis reveals various system and cognitive errors, plus
multiple error mechanisms and … Cognitive issues in diagnostic error
We conclude where most diagnostic error discussions begin—with … cognitive errors.
1) Hindsight bias and difficulties weighing prior probabilities bedeviled our efforts … Preliminary analysis revealed various system and cognitive errors, plus multiple error
mechanisms and … The importance of cognitive errors in diagnosis and strategies to minimize them.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-stories.pdf
July 01, 2020 - ”
- Mark Turner, cognitive scientist, linguist & author
“In the future, your survey should account
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
January 01, 2007 - and development of the TR & R Project are described
Safety and Errors in Emergency Medical Care
Cognitive … litigation brought against emergency physicians arises from delayed or
missed diagnoses.2 Traditionally, cognitive … demonstrated that formal trauma patient algorithms encourage
consistency, reduce error rates, prevent cognitive … of the time.10 An important reason for preventable
adverse events in clinical care was found to be cognitive … The importance of cognitive errors in
diagnosis and strategies to minimize them.
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www.ahrq.gov/sites/default/files/2024-01/johnson-baughman-report.pdf
January 01, 2024 - that the use of electronic prescription writing tools decreases
medication errors by improving the cognitive … interactions or allergies, may be significantly decreased when pharmacists are made aware of the
cognitive … Those errors include cognitive errors (wrong medication, no medication for an
appropriate indication … Modernization
Act.16 Despite the advantages that e-prescribing with decision support may confer to the
cognitive … dispensing errors when that activity was associated with
interruptions.20
The inability to communicate the cognitive
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www.ahrq.gov/sites/default/files/2024-01/sangasubana-report.pdf
January 01, 2024 - questionnaires that can
test experimentally manipulated information in elderly subjects with diminished cognitive … risk perceptions of
OTCs, especially for the elderly, who are high-risk patients with diminished cognitive … To address the issue of the elderly's diminished cognitive ability, the questionnaire was revised with … for them, because there was confusion over label and scenario risk manipulations due to
diminished cognitive … research, because it tested experimentally
manipulated information in elderly subjects with diminished cognitive
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/mhsa.html
June 01, 2018 - for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral … Using cognitive-behavioral therapy ( Tarrier, et al., 2008 ). … Ongoing research shows promising results for Internet-based cognitive-behavioral therapy and psychoeducation … Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis.
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www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
January 01, 2025 - items that were developed through extensive literature
review, content analysis of existing tools, cognitive … Content validity was established through cognitive interviews
with PCPs and primary care experts.39 … Cognitive Technol. 1998;3:24-32.
18. Reason J. Human error: models and management. … Cognitive and initial psychometric testing of the
Errors of Care Omission Survey (ECOS): a new patient
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www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdf
January 01, 2025 - Cognitive debiasing 1: origins of bias and theory of debiasing. … Cognitive debiasing 2: impediments to and strategies for change.
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www.ahrq.gov/news/newsroom/case-studies/202301.html
October 01, 2024 - Those at highest risk for hypoglycemia are patients over 75 years old with dementia or cognitive impairment
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - diagnosis
Create Independent Checks (CUSP Element)
Key Perinatal Safety Elements
Examples
Use cognitive … · Cognitive aids such as checklists, algorithms, or protocols may improve clinical team response and … communication related to—
· situational awareness,
· ability to get additional help quickly,
· use of cognitive
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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_facguide.pdf
May 01, 2017 - This tool also offers a sample cognitive aid for
standardized EFM nomenclature as an
appendix. … A sample cognitive
aid with NICHD nomenclature is provided in
the appendix of the Safe EFM tool. … related to the following:
• Situational awareness
• Ability to get additional help quickly
• Use of cognitive
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www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
March 01, 2016 - The report includes composite measures, which reduce the cognitive load to process the
report’ … Technique #1: Cognitive testing
Cognitive testing is conducted through one-on-one, in-person meetings … See Text Box 4 for sample questions that cognitive testing can
answer.
Text Box 4. … Cognitive testing can be used
throughout the development process. … What cognitive science tells us about the design of reports for consumers.
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www.ahrq.gov/hai/tools/mvp/modules/technical/intro-early-mobility-fac-guide.html
February 01, 2017 - And finally, it mitigates the longer term physical, cognitive, and functional disabilities from critical … mitigate both short- and long-term complications from critical illness, such as muscle weakness and cognitive