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psnet.ahrq.gov/issue/role-cognition-generating-and-mitigating-clinical-errors
January 07, 2015 - This review examines cognitive aspects of human error that affect patient safety, methods to augment … potential for educational approaches like virtual reality simulation to train physicians to manage cognitive … December 21, 2018
WebM&M Cases
Cognitive Overload in … Pills, Same Drug
June 1, 2005
The multitasking clinician: decision-making and cognitive
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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/curated-library/diagnostic-safety-improvement
April 17, 2025 - Classic
The importance of cognitive errors in diagnosis and strategies to minimize them … This article summarizes a series of cognitive error types referred to as “cognitive dispositions to respond … System 1 and System 2 thinking, human factors, and cognitive biases are discussed. … ways evidence is collected based on the diagnostic purpose: optimal clinical care (e.g., usefulness of testing … – reports of return visits for the same or worsening symptoms, interpersonal issues, and diagnostic testing
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psnet.ahrq.gov/innovations
February 26, 2025 - 2024
Discover how the TWISST process, combining simulation-based clinical systems testing … EMERGING INNOVATIONS
Demonstrating the value of a standardized cognitive assessment tool through … Pharmacy
(2)
Error Types
Active Errors
(7)
Cognitive … URL
Discover how the TWISST process, combining simulation-based clinical systems testing … Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional
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psnet.ahrq.gov/issue/enhancing-implementation-i-pass-handoff-tool-using-provider-handoff-task-force-comprehensive
March 09, 2022 - October 19, 2022
Testing an intervention to improve health care worker well-being during … January 27, 2019
Usability testing of a mobile app to report medication errors anonymously … September 9, 2015
Why patient summaries in electronic health records do not provide the cognitive
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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/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/node/33570/psn-pdf
June 15, 2024 - This work has been informed by the field of cognitive psychology, which studies how individuals process … While heuristics are ubiquitous and useful, researchers
have used categories developed in cognitive … /web-mm/crushing-chest-pain-missed-opportunity
Cognitive Bias Definition Example
Anchoring
heuristic … Recent systematic reviews have assessed the evidence base of interventions to
prevent cognitive errors … https://psnet.ahrq.gov/issue/cognitive-interventions-reduce-diagnostic-error-narrative-review
https:
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psnet.ahrq.gov/issue/more-words-interpersonal-communication-cognitive-bias-and-diagnostic-errors
March 11, 2013 - Commentary
'More than words' - interpersonal communication, cognitive bias and diagnostic … ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. … Cognitive biases and poor communication among providers can lead to diagnostic errors . … ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. … November 11, 2020
Cognitive bias impact on management of postoperative complications,
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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/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/primer/diagnostic-errors
June 15, 2024 - This work has been informed by the field of cognitive psychology , which studies how individuals process … While heuristics are ubiquitous and useful, researchers have used categories developed in cognitive psychology … several types of errors that clinicians commonly make due to incorrect applications of heuristics: Cognitive … While cognitive biases on the part of individual clinicians play a role in many diagnostic errors, underlying … Recent systematic reviews have assessed the evidence base of interventions to prevent cognitive errors
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - recommendations involved some changes in her anti-epileptic medications, but on hospital day 7, they recommended testing … In an academic health system, the ordering provider is often a trainee, who may be at high risk for cognitive … This phrase serves the same notational purpose as “continue to monitor”; it provides the author cognitive … patient, changing our internal narrative and giving the patient a new diagnosis can be a significant cognitive … Systems 1 and 2 thinking processes and cognitive reflection testing in medical students.
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psnet.ahrq.gov/issue/communicating-critical-test-results
May 24, 2006 - September 6, 2023
A perfect storm averted: flawed systems, a dropped ball, and cognitive … February 15, 2010
Finding blunders in thyroid testing: experience in newborns.
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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/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - Additional internal factors include mental health issues such as fear of falling, cognitive impairment … Lastly, she was simply at risk for falling because of her impaired cognitive status, as she may have … Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment … Testing the impact of FFC-AL-EIT on psychosocial and behavioral outcomes in assisted living. … Testing the implementation of function-focused care in assisted living settings.
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psnet.ahrq.gov/issue/clinicians-expectations-benefits-and-harms-treatments-screening-and-tests-systematic-review
May 05, 2021 - Author(s)
Accuracy of practitioner estimates of probability of diagnosis before and after testing … September 12, 2018
Countering cognitive biases in minimising low value care.
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psnet.ahrq.gov/issue/situativity-family-social-cognitive-theories-clinical-reasoning-and-error
June 08, 2022 - Special or Theme Issue
Situativity: A Family of Social Cognitive Theories for Clinical … Citation Text:
Situativity: A Family of Social Cognitive Theories for Clinical Reasoning and Error. … Cite
Citation
Citation Text:
Situativity: A Family of Social Cognitive
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psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop
May 19, 2021 - August 17, 2022
Society for Maternal-Fetal Medicine Special Statement: cognitive bias … experience of obstetric patients and health care workers after implementation of universal SARS-CoV-2 testing
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - for cognitive ills." … Cognitive forcing strategies in clinical decisionmaking. … The cognitive psychology of missed diagnoses. … What types of cognitive processes are used to make the decision? … April 3, 2018
When diagnostic testing leads to harm: a new outcomes-based approach for