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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - Laboratory testing showed only abnormal transaminases. … This case is demonstrative of cognitive errors associated with lack of knowledge of the features of, … Many of these errors are best categorized as cognitive and relate to a clinician’s decision-making, … testing those with risk factors or symptoms that suggest SEA. … Cognitive errors in diagnosis: Instantiation, classification, and consequences.
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psnet.ahrq.gov/issue/matts-story-learning-heartbreak
August 07, 2024 - Discussing an error that resulted in the death of a young man, this commentary reviews how cognitive … January 13, 2016
Improving infusion pump safety through usability testing.
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psnet.ahrq.gov/issue/when-misdiagnosis-child-abuse
June 09, 2021 - Diagnostic decision-making is susceptible to cognitive biases and error in stressful situations. … March 30, 2022
When no news is bad news: improving diagnostic testing communication through
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psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
November 30, 2022 - Commentary
A perfect storm averted: flawed systems, a dropped ball, and cognitive … A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis … delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive … A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis … October 5, 2016
Cognitive and implicit biases in nurses' judgment and decision-making
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psnet.ahrq.gov/issue/perception-usability-and-implementation-metacognitive-mnemonic-check-cognitive-errors
September 02, 2020 - Perception of the usability and implementation of a metacognitive mnemonic to check cognitive … Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors … Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors … August 12, 2020
Effect of cognitive aids on adherence to best practice in the treatment … March 20, 2019
A cognitive forcing tool to mitigate cognitive bias—a randomised control
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psnet.ahrq.gov/issue/mistakes-some-deadly-haunt-county-jails
March 01, 2017 - March 1, 2017
Seattle pilot’s misdiagnosis highlights challenges around coronavirus testing … January 16, 2019
Clinical reasoning in dire times- analysis of cognitive biases in clinical
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psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety
May 13, 2020 - November 18, 2015
Situativity: A Family of Social Cognitive Theories for Clinical Reasoning … Resources
Measuring the rate of manual transcription error in outpatient point-of-care testing
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psnet.ahrq.gov/sites/default/files/2020-07/spotlight_nstemi.pdf
January 01, 2020 - of preventable errors are diagnostic errors (Harvard Medical
Practice Study)
- Rooted in several cognitive … biases
- Address cognitive errors with objective information to assist medical decision-
making
- … much as 51% of
curbside consultations
- Asymmetric information can lead to unnecessary, expensive testing … Take-Home Points (3)
26
• Cognitive biases—availability bias, anchoring bias,
confirmation bias, … Cognitive interventions to reduce diagnostic error: a narrative review.
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psnet.ahrq.gov/issue/using-voluntary-reports-physicians-learn-diagnostic-errors-emergency-medicine
February 17, 2016 - Cognitive errors and system factors (e.g., inefficient processes and high workload) were prevalent. … These results demonstrate the need to address diagnostic safety with both cognitive training interventions … July 15, 2015
Cognitive interventions to reduce diagnostic error: a narrative review. … January 9, 2019
Cognitive error in an academic emergency department. … October 10, 2018
How common are cognitive errors in cases presented at emergency medicine
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psnet.ahrq.gov/issue/hospital-system-barriers-rapid-response-team-activation-cognitive-work-analysis
September 09, 2015 - Study
Hospital system barriers to rapid response team activation: a cognitive work … CE: Original research: hospital system barriers to rapid response team activation: a cognitive work analysis … CE: Original research: hospital system barriers to rapid response team activation: a cognitive work analysis
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - The term "cognitive bias" is often used to describe a heuristic that, when applied in a specific situation … In general, there are three main types of cognitive biases that lead to diagnostic errors: (i) hasty … This involves the conscious, effortful generation and testing of diagnostic hypotheses. … The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking … A vignette study to assess recognition of cognitive biases in clinical case workups.
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - The term "cognitive bias" is often used to describe a heuristic that, when applied in a
specific situation … In general, there are three main types of cognitive biases that lead to diagnostic errors: (i) hasty … This involves the conscious, effortful generation and testing of diagnostic
hypotheses. … The causes of errors in clinical
reasoning: cognitive biases, knowledge deficits, and dual process thinking … A
vignette study to assess recognition of cognitive biases in clinical case workups.
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psnet.ahrq.gov/issue/variation-electronic-test-results-management-and-its-implications-patient-safety-multisite
June 02, 2021 - strategies clinicians use to enhance test result management including paper-based manual processes, cognitive … , 2019
Measuring the rate of manual transcription error in outpatient point-of-care testing
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - Cognitive Errors
Trying to perform a cognitive autopsy to understand why the resident committed the … Armed with this understanding, they can apply cognitive forcing strategies to reduce the occurrence of … Cognitive forcing strategies in clinical decisionmaking. … The importance of cognitive errors in diagnosis and strategies to minimize them. … January 15, 2009
Portable advanced medical simulation for new emergency department testing
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psnet.ahrq.gov/issue/are-national-efforts-reduce-drug-name-confusion-paying
December 27, 2018 - attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing … May 2, 2018
Cognitive tests predict real-world errors: the relationship between drug
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psnet.ahrq.gov/issue/system-wide-hospital-child-maltreatment-patient-safety-program
September 15, 2021 - pediatricians (CAPs) to intervene and address potential errors (e.g., history taking, injury identification, testing … for occult injuries , and cognitive analysis) and to identify patients who require immediate intervention
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psnet.ahrq.gov/issue/why-patient-safety-challenge-insights-professionalism-opinions-medical-students-research
January 26, 2022 - Findings suggest that physician and medical student opinions are often influenced by cognitive dissonance … February 16, 2022
Development and usability testing of the Agency for Healthcare Research
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psnet.ahrq.gov/issue/spectrum-hospitalization-associated-harm-elderly
April 06, 2022 - potential patient harm that can occur during hospitalization for older adults, including unnecessary testing … or procedures, nosocomial infections, medical errors, falls , functional or cognitive decline, and
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psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-test-results
April 03, 2024 - September 2, 2018
Cognitive interventions to reduce diagnostic error: a narrative review … December 30, 2014
Point-of-care testing, medical error, and patient safety: a 2007 assessment
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psnet.ahrq.gov/issue/prevalence-and-predictability-low-yield-inpatient-laboratory-diagnostic-tests
November 13, 2024 - June 2, 2019
System-related and cognitive errors in laboratory medicine. … December 31, 2014
Responding to large-scale testing errors.