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psnet.ahrq.gov/issue/impact-initial-response-covid-19-long-term-care-people-intellectual-disability-interrupted
May 11, 2022 - November 25, 2020
Flexibilization of science, cognitive biases, and the COVID-19 pandemic … experience of obstetric patients and health care workers after implementation of universal SARS-CoV-2 testing
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psnet.ahrq.gov/issue/sex-bias-pain-management-decisions
June 07, 2023 - June 7, 2023
Cognitive tests predict real-world errors: the relationship between drug … February 26, 2020
The Healthcare Complaints Analysis Tool: development and reliability testing
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psnet.ahrq.gov/issue/effectiveness-do-not-interrupt-bundled-intervention-reduce-interruptions-during-medication
August 26, 2020 - October 19, 2022
User-testing guidelines to improve the safety of intravenous medicines … Safety and Quality
April 26, 2023
Impact of interruptions, distractions, and cognitive
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psnet.ahrq.gov/issue/developing-and-aligning-safety-event-taxonomy-inpatient-psychiatry
September 14, 2022 - May 4, 2022
Development and usability testing of the Agency for Healthcare Research and … April 27, 2022
Investigating the impact of cognitive bias in nursing documentation on
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psnet.ahrq.gov/issue/can-decision-support-combat-incompleteness-and-bias-routine-primary-care-data
July 29, 2020 - August 28, 2019
Testing and improving the acceptability of a web-based platform for collective … Ambulatory Clinic or Office
Information Professionals
Primary Care
Diagnostic Errors
Cognitive
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - Anchoring, a type of cognitive bias, occurs when a clinician fixates on features of a specific diagnosis … Testing every asthmatic for PE is unreasonable. … On an individual level, physicians should be aware of, and take action to address, their cognitive biases … The importance of cognitive errors in diagnosis and strategies to minimize them. … Pneumothorax
August 25, 2021
WebM&M Cases
Cognitive
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - We looked at the history and physical, lab testing, assessment, and follow-up. … In terms of cognitive support and visual display, think about what a profound display tool the lab flowsheet … We have to really think of supporting the infrastructure to make cognitive work in medicine easier and
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - several prevention strategies to mitigate diagnostic error that address systems causes and
individual cognitive … processes and system-related factors are responsible for most
errors.18 The most common cognitive problems … Most notably, many diagnostic errors
studied were the result of both system and cognitive problems occurring … the likelihood of
incorrect diagnosis, and that physician overconfidence is a major contributor to cognitive … All in all, both system and cognitive causes of diagnostic error
led to the tragic outcome presented
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - several prevention strategies to mitigate diagnostic error that address systems causes and individual cognitive … have not been fully elucidated, research in the field suggests that both the individual clinician’s cognitive … processes and system-related factors are responsible for most errors. 18 The most common cognitive … Most notably, many diagnostic errors studied were the result of both system and cognitive problems occurring … All in all, both system and cognitive causes of diagnostic error led to the tragic outcome presented.
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - The PE Rule-out Criteria (PERC), developed to decrease unnecessary testing
for PE, includes abnormal … Anchoring, a type of cognitive bias, occurs when a clinician fixates on features of a
specific diagnosis … Testing every asthmatic for PE is
unreasonable. … On an individual level, physicians should be aware of, and take action to address, their
cognitive biases … The importance of cognitive errors in diagnosis and strategies to minimize them.
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Learning Objectives
Understand how cognitive biases such as framing errors and premature closure … In summary, multiple common cognitive errors may have contributed to the patient’s outcome. … The importance of cognitive errors in diagnosis and strategies to minimize them. … The use of cognitive aids during emergencies in anesthesia: a review of the literature. … Cognitive forcing strategies in clinical decisionmaking.
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psnet.ahrq.gov/issue/human-factors-engineering-tool-medical-device-evaluation-hospital-procurement-decision-making
June 28, 2017 - conducted a human factors evaluation of three infusion pumps, combining heuristic assessment and user testing … October 13, 2021
Development and testing of an objective structured clinical exam (OSCE
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - biases that contribute to anchoring
Describe steps to improve cognitive awareness of diagnostic errors … 75% of diagnostic errors have a cognitive component
Two overarching cognitive components are:
The tendency … Arch Intern Med. 2009;169:1881-1887. http://www.ncbi.nlm.nih.gov/pubmed/19901140
9
Cognitive Errors … name=availabilitybias
11
Cognitive Biases & Anchoring
Multiple cognitive biases contribute to anchoring … ClinicalReasoning
18
Cognitive Awareness (2)
Cognitive awareness may also be improved through teamwork
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - infarction (which can present as monoparesis), brain
infarcts with convulsions, and strokes with primarily cognitive … 28
Laboratory Testing (1)
• Inherent to this discussion is whether the hospital in this case had … – Standard laboratory testing in patients presenting with AIS includes only the point-
of-care blood … decisions regarding thrombolysis in a patient
presenting with a possible stroke involves a dual-process cognitive … • While this system permits cognitive offloading and expedites critical decisions, it
may be more
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psnet.ahrq.gov/issue/mortality-trends-after-voluntary-checklist-based-surgical-safety-collaborative
September 24, 2017 - June 2, 2015
Crisis checklists for the operating room: development and pilot testing. … May 27, 2010
Factors associated with the use of cognitive aids in operating room crises
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psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-pathology-errors-cancer-diagnoses
March 28, 2012 - July 20, 2009
Dissemination of Lean methods to improve Pap testing quality and patient … April 10, 2013
Cognitive errors and logistical breakdowns contributing to missed and
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psnet.ahrq.gov/issue/patient-physician-medical-assistant-and-office-visit-factors-associated-medication-list
June 28, 2017 - April 12, 2019
Point-of-care cognitive support technology in emergency departments: a … "Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing
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psnet.ahrq.gov/issue/evaluation-outcomes-national-patient-initiated-second-opinion-program
July 15, 2015 - July 15, 2015
Cognitive interventions to reduce diagnostic error: a narrative review. … December 16, 2020
Development and usability testing of the Agency for Healthcare Research
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psnet.ahrq.gov/issue/rare-adverse-medical-events-va-inpatient-care-reliability-limits-using-patient-safety
February 27, 2008 - January 4, 2017
Awareness and use of a cognitive aid for anesthesiology. … October 13, 2010
Testing the association between Patient Safety Indicators and hospital
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psnet.ahrq.gov/issue/impact-diagnostic-decision-support-system-consultation-perceptions-gps-and-patients
June 28, 2017 - Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive … August 28, 2019
Testing and improving the acceptability of a web-based platform for collective