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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive … rarity of TTP and the often ambiguous and non-specific clinical presentation (eg, fever, anemia),
cognitive … The importance of cognitive errors in diagnosis and strategies to minimize them. … Cognitive Technologies Laboratory Web site.
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psnet.ahrq.gov/issue/lost-art-history-and-physical
May 08, 2013 - May 29, 2019
A cognitive forcing tool to mitigate cognitive bias—a randomised control … See More About The Topic
Physicians
Educators
Medicine
Diagnostic Errors
Cognitive
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psnet.ahrq.gov/issue/medication-safety-gaps-english-pediatric-inpatient-units-exploration-using-work-domain
April 17, 2024 - Several contributory factors were identified, including resource limitations, cognitive demands, and … July 31, 2019
Physician antipsychotic overprescribing letters and cognitive, behavioral
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psnet.ahrq.gov/issue/diagnostic-error-result-drug-laboratory-test-interactions
November 21, 2018 - Topic
Health Care Providers
Information Professionals
Pathology and Laboratory Medicine
Cognitive
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - testing, 17 typical infusion pump users attempted several realistic clinical scenarios on 3 infusion … to industry their commitment to HFE aspects of design.(13) Other hospitals
are employing usability testing … in HFE principles,
can detect and suggest fixes for many potential vulnerabilities.(14) Usability testing … can aid in the improved
design of pump labels and other cognitive aids (eg, quick-reference cards). … Usability testing can also guide the focus and content of in-service
training on infusion pumps.
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psnet.ahrq.gov/node/43899/psn-pdf
February 18, 2015 - Development and validation of a taxonomy of adverse
handover events in hospital settings.
February 18, 2015
Andersen HB, Siemsen IMD, Petersen LF, et al. Development and validation of a taxonomy of adverse
handover events in hospital settings. Cognition, Technology & Work. 2014;17(1). doi:10.1007/s10111-014-
0303-…
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - First, it wastes the time and cognitive effort of users, who have to defeat a dysfunctional system. … Usability testing with typical cases probably would have missed this design flaw, as this was not a typical … A cognitive systems engineering (CSE) ( 9,10 ) approach would have been more likely to catch this flaw … Cognitive systems engineering: new wine in new bottles. Int J Hum Comput Stud. 1999;51:339-356. … Joint Cognitive Systems: Foundations of Cognitive Systems Engineering.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - ʺReflexiveʺ Diagnosis (2)
He saw two different providers who did not order any additional diagnostic testing … considering reasonable alternatives after an initial diagnosis was reached) may be the most common cognitive … available, there appears to have been a delay in diagnosis of a spinal cord injury
There may have been a cognitive … even in the face of disconfirming evidence)
11
11
Solutions to Diagnostic Errors
Solutions to cognitive
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psnet.ahrq.gov/issue/establishing-multi-institutional-quality-and-patient-safety-consortium-collaboration-across
June 24, 2009 - Commentary
Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.
Citation Text:
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium: collab…
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psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - No additional diagnostic testing was pursued at that time. … strong advocate (her mother), she felt that physicians would not have pursued additional diagnostic testing … The first gynecologist seems to have not considered other etiologies as no testing was performed. … The cognitive bias of anchoring (wherein first diagnostic impressions persist or are even cemented despite … O’Sullivan ED, Schofield.SJ Cognitive bias in clinical medicine.
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psnet.ahrq.gov/issue/biggest-mistake-doctors-make
October 09, 2013 - Diagnostic Safety and Quality
April 26, 2023
Effect on diagnostic accuracy of cognitive … July 3, 2016
Cognitive interventions to reduce diagnostic error: a narrative review.
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psnet.ahrq.gov/issue/impact-health-information-technology-management-and-follow-test-results-systematic-review
August 19, 2020 - to Reduce Missed and Delayed Diagnoses of Cancer
July 31, 2023
The effect of cognitive
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - effect. 2 Distinguishing between the contributions to diagnostic errors of systems problems versus cognitive … Cognitive errors were made by the intern and the sonographer, who both lacked sufficient knowledge and … Several types of cognitive biases are known to influence clinical decision-making, especially in the … Take-Home Points
Patient-related factors, cognitive errors, and systems factors are common categories … in early labor
Communication among members of work teams is critical for avoiding perpetuation of cognitive
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psnet.ahrq.gov/issue/completion-recommended-tests-and-referrals-telehealth-vs-person-visits
January 31, 2024 - December 20, 2023
Detection rates of mild cognitive impairment in primary care for the
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psnet.ahrq.gov/innovation/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 08, 2021 - recommendation from the HS-ASP team (e.g., recommendations to consider alternative diagnoses, request additional testing … The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive
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psnet.ahrq.gov/node/844772/psn-pdf
September 18, 2019 - /diagnostic-errors
https://psnet.ahrq.gov/issue/bias-eye-beholder-vignette-study-assess-recognition-cognitive-biases-clinical-case-workups
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psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
July 12, 2023 - This commentary advocates for studying behavioral, cognitive, linguistic , environmental , and technological … October 19, 2022
How to mitigate the effects of cognitive biases during patient safety
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psnet.ahrq.gov/issue/missed-breast-cancer-effects-subconscious-bias-and-lesion-characteristics
February 02, 2022 - This article discusses the cognitive processes that can lead to unconscious bias in breast cancer imaging … December 23, 2020
The role of cognitive bias in breast radiology diagnostic and
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - for cognitive ills." … The importance of cognitive errors in diagnosis and strategies to minimize them. … Cognitive forcing strategies in clinical decisionmaking. … The cognitive psychology of missed diagnoses. … What types of cognitive processes are used to make the decision?
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - Case Objectives Provide an overview of transitions in continuously operating industries Review cognitive … the rarity of TTP and the often ambiguous and non-specific clinical presentation (eg, fever, anemia), cognitive … The importance of cognitive errors in diagnosis and strategies to minimize them. … Cognitive Technologies Laboratory Web site.