-
psnet.ahrq.gov/issue/finding-and-fixing-diagnosis-errors-can-triggers-help
January 31, 2024 - December 2, 2020
Development and usability testing of the Agency for Healthcare Research
-
psnet.ahrq.gov/issue/resilient-actions-diagnostic-process-and-system-performance
November 13, 2024 - December 12, 2012
Cognitive errors and logistical breakdowns contributing to missed and
-
psnet.ahrq.gov/issue/increased-patient-safety-related-incidents-following-transition-daylight-savings-time
May 19, 2021 - Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive
-
psnet.ahrq.gov/issue/structural-racism-60-year-old-black-woman-breast-cancer
December 17, 2020 - May 4, 2022
Error and cognitive bias in diagnostic radiology. … April 13, 2022
Description of the role of pharmacist independent double checks during cognitive
-
psnet.ahrq.gov/issue/testimonial-injustice-linguistic-bias-medical-records-black-patients-and-women
July 28, 2021 - Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive … March 31, 2021
Flexibilization of science, cognitive biases, and the COVID-19 pandemic
-
psnet.ahrq.gov/issue/role-knowledge-and-reasoning-processes-predictors-resident-physicians-susceptibility
March 18, 2020 - March 18, 2020
Improving handoff by deliberate cognitive processing: results from a randomized … October 4, 2023
Effect on diagnostic accuracy of cognitive reasoning tools for the workplace
-
psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - Even when properly prepared, however, the high stress of airway emergencies can lead to cognitive overload … Several training protocols and cognitive aids have been published to assist clinicians in early detection … Training protocols and cognitive aids, as well as emergency supply packs, can be helpful tools for clinicians … THYRAID: a cognitive aid for the management of neck haematoma following thyroid surgery. … WebM&M Cases
Agitated Delirium Contributes to Missed Testing
-
psnet.ahrq.gov/continuing-education
February 26, 2025 - Pharmacy
(4)
Error Types
Active Errors
(118)
Cognitive … importance of imaging in patients with high-risk abdominal pain, and how to mitigate the influence of cognitive … A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Garth Utter, MD | … The commentary highlights the cognitive pitfalls associated with managing and processing large volumes
-
psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - However, usability testing has demonstrated that CPOE systems with clinical decision support still … commercial CPOE system found that the system required clinicians to perform many new tasks, increasing cognitive … integration of human factors engineering principles, including real-world usability and vulnerability testing
-
psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - NSS cancer pathways teams, researchers identified distinct functions of the team, clustered in pre-testing … assessment and information gathering and post-testing interpretation and management. … importance of imaging in patients with high-risk abdominal pain, and how to mitigate the influence of cognitive
-
psnet.ahrq.gov/node/45125/psn-pdf
January 26, 2023 - /fda-and-ismp-lists-look-alike-drug-names-recommended-tall-man-letters
https://psnet.ahrq.gov/issue/cognitive-tests-predict-real-world-errors-relationship-between-drug-name-confusion-rates
-
psnet.ahrq.gov/issue/relationship-between-professional-burnout-and-quality-and-safety-healthcare-meta-analysis
April 24, 2018 - March 8, 2017
Cognitive biases associated with medical decisions: a systematic review
-
psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - confirmation as the first-line method in adults, whereas guidelines from Europe and Australia favor pH testing … , utilizing radiographic testing only when the pH method has failed or when a patient is considered at … reflex, or critical illness. 8 The most important advantage of non-radiographic methods, such as pH testing … to distinguish between gastric and pulmonary aspirates. 8 One study proposed using pH and bilirubin testing … January 15, 2025
WebM&M Cases
A Cognitive and Communication
-
psnet.ahrq.gov/issue/systems-engineering-analysis-diagnostic-referral-closed-loop-processes
December 07, 2022 - December 6, 2023
Detection rates of mild cognitive impairment in primary care for the
-
psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - The importance of confirmation bias and other cognitive pitfalls that affect diagnostic reasoning have … Achieving quality in clinical decision making: cognitive strategies and detection of bias. … The importance of cognitive errors in diagnosis and strategies to minimize them.
-
psnet.ahrq.gov/node/34769/psn-pdf
March 28, 2005 - normalization of deviance,” a phenomenon that shares many features with the “status quo bias”
discussed in cognitive
-
psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Antigen tests have the potential to yield false negatives for a variety of reasons, such as testing too … results could occur with antigen tests , so healthcare providers were encouraged to do routine follow-up testing … (reflex testing) with PCR testing when appropriate, and to consider the expected occurrence of false … Diagnostic Safety
Failure to Close the Loop on Diagnostic Testing and Referrals
While the issues … In theory, these strategies should represent “low-hanging fruit” (compared to the many cognitive challenges
-
psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
November 11, 2020 - Commentary
Five strategies for a safer EHR modernization journey.
Citation Text:
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
Copy Citation
Format:
DOI Google Sch…
-
psnet.ahrq.gov/issue/nurses-satisfaction-medication-administration-point-care-technology
January 09, 2008 - February 24, 2011
Cognitive errors and logistical breakdowns contributing to missed and
-
psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - staff are prevalent during the normal course of care delivery, and even more so in times of crisis when cognitive … new units or entire hospitals for surge capacity is occurring in response to the COVID-19 pandemic, cognitive … analysis can be used to develop standardized processes for patient screening and routing, diagnostic testing