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effectivehealthcare.ahrq.gov/sites/default/files/pdf/hip-fracture-pain_clinician.pdf
May 01, 2011 - Applicability of current studies is limited, as patients in
institutional settings and those with cognitive
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psnet.ahrq.gov/perspective/response-failure-report-march-2007
June 01, 2007 - Soil, Not the Seed: The Real Problem with Root Cause Analysis
July 1, 2008
Cognitive
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digital.ahrq.gov/sites/default/files/docs/resource/Dataform_2_Chart_Review.pdf
June 16, 2021 - 2 Yes
attacks (TIA’s) ever
8.5 DEMENTIA ____ 1 No
Have chronic cognitive
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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-Webster_76.pdf
July 18, 2008 - These authors acknowledged
the relationship of diagnostic errors with the cognitive process and complexity … Cognitive errors and the decisionmaking process can be seen as failures in perception, failed
heuristics … Despite the seemingly esoteric view of cognitive failures, often problems seen in offices and
clinics … The importance of cognitive errors in
diagnosis and strategies to minimize them.
-
effectivehealthcare.ahrq.gov/get-involved/nominated-topics/in-patients-with-dementia-what-is-the-effectiveness-of-psychological-treatment-ie-non-pharmacological-eg-cognitive-or-behavioral-therapy-for-individuals-with-dementia-environmental-and-behavioral-interventions-to-address-beh
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
January 01, 2004 - complexity and the interdisciplinary scope of
the patient safety problem, including factors related to the cognitive … action); and organizational structures (reporting
mechanisms, barriers, and outcome measures).3
Cognitive … related to patient safety and medical
errors.12
The interplay among factors
These three domains—cognitive
-
www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
January 01, 2025 - Finally, we performed
human reliability and cognitive task analyses to establish quantitative models … Though the direct observations provided some empiric data for modeling aspects of cognitive
reliability … models.
5
Some of these sources provided empiric data from non-healthcare domains in which the
cognitive
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-250-cannabis-2025-surv-rep-update-executive-sum.pdf
January 01, 2025 - • Other key adverse event outcomes (psychosis, cannabis use disorder, cognitive
deficits) and outcomes … Other prioritized adverse
events (cannabis use disorder [CUD], psychosis, cognitive deficits) and the … function or disability, effect on opioid use, and
longer-term adverse events, such as CUD, psychosis, and cognitive
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - Cognitive debiasing 2: impediments to and strategies for change.
-
cdsic.ahrq.gov/sites/default/files/2025-09/Final%20508_Measuring%20Patient%20Experience%20of%20PC%20CDS_0.pdf
January 01, 2025 - We then conducted seven virtual cognitive testing sessions with seven patient advocates. … To create the
final question bank for field-testing, we revised the survey questions based on cognitive … Survey Question Refinement and Finalization
We interviewed patient advocates to cognitive test the … We implemented an iterative approach to question refinement based on cognitive testing, revising the … Cognitive Testing.
-
digital.ahrq.gov/sites/default/files/Final%20508_Measuring%20Patient%20Experience%20of%20PC%20CDS_0.pdf
December 03, 2024 - We then conducted seven virtual cognitive testing sessions with seven patient advocates. … To create the
final question bank for field-testing, we revised the survey questions based on cognitive … Survey Question Refinement and Finalization
We interviewed patient advocates to cognitive test the … We implemented an iterative approach to question refinement based on cognitive testing, revising the … Cognitive Testing.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
June 02, 2025 - New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - (Yount)
Introducing the AHRQ SOPS
Health IT Patient Safety
Supplemental Items
Naomi Yount, PhD
Westat
Health IT Patient Safety
Supplemental Items
• Supplemental item set that can be added
to the end of the Hospit…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops_101_webcast-2022-gray.pdf
January 01, 2022 - Understanding SOPS® Surveys: A Primer for New Users - Gray
Overview of the SOPS Surveys
Laura Gray, MPH
Senior Study Director
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
14
What are the SOPS Surveys?
• Surveys of providers and staff about the extent to which their
organizational …
-
www.ahrq.gov/talkingquality/distribute/placement/settings.html
January 01, 2023 - Settings: Finding the Audience for a Health Care Quality Report
Reconfirming Who Your Audience Is
Before you can identify appropriate settings, you need to have a clear and shared sense of the audience you are trying to reach. Assuming your resources are limited, you’ll probably need to set priorities within …
-
psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
March 29, 2023 - Review
Classic
Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies.
Citation Text:
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events in…
-
psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
April 08, 2018 - Study
Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.
Citation Text:
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and fa…
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digital.ahrq.gov/ahrq-funded-projects/synthesizing-lessons-learned-using-health-information-technology/annual-summary/2012
January 01, 2012 - Synthesizing Lessons Learned Using Health Information Technology - 2012
Project Name
Synthesizing Lessons Learned Using Health Information Technology
Principal Investigator
Nemeth, Lynne
Organization
Medical University of South Carolina
Funding Mechanism
PAR: HS08-2…
-
digital.ahrq.gov/ahrq-funded-projects/synthesizing-lessons-learned-using-health-information-technology/annual-summary/2011
January 01, 2011 - Synthesizing Lessons Learned Using Health Information Technology - 2011
Project Name
Synthesizing Lessons Learned Using Health Information Technology
Principal Investigator
Nemeth, Lynne
Organization
Medical University of South Carolina
Funding Mechanism
PAR: HS08-2…
-
digital.ahrq.gov/ahrq-funded-projects/synthesizing-lessons-learned-using-health-information-technology/annual-summary/2010
January 01, 2010 - Synthesizing Lessons Learned Using Health Information Technology - 2010
Project Name
Synthesizing Lessons Learned Using Health Information Technology
Principal Investigator
Nemeth, Lynne
Organization
Medical University of South Carolina
Funding Mechanism
PAR: HS08-2…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/about/measures-child-hcahps-909.pdf
March 20, 2017 - Cognitive testing with parents indicated that the use of these groupings made
it easier for respondents … of 3 items)
2 To learn more about reducing the cognitive