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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool10_dc_checklist.docx
November 01, 2015 - The patient’s condition at discharge
Include cognitive function.*
Include functional status.*
Include
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www.ahrq.gov/news/newsletters/e-newsletter/943.html
January 01, 2025 - Cognitive biases and artificial intelligence . … Testing and masking policies and hospital-onset respiratory viral infections.
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www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
December 01, 2012 - Weaker Actions
Intermediate Actions
Stronger Actions
Double check
Checklists or cognitive … map
Additional study or analysis
Software enhancement or modifications
New device usability testing
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
April 02, 2025 - ■ Post-discharge social and environmental conditions significantly influence cognitive outcome. … Testing
■ Adjust an infant’s age for prematurity until he/she is 2 years adjusted age. … ■ Err on the side of caution, and refer the infant for formal testing early rather than waiting. … Outcomes
Poor head growth by 8 months corrected age is a strong predictor of poor cognitive function, … Sleep Patterns and Cognitive Development
■ Development of sleep-wake cycles likely has major impact
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/literacy/about_the_health_literacy_item_set_for_hospitals_911.pdf
October 01, 2015 - • Stakeholder meeting to obtain feedback
• Development of domains and an initial set of items
• Cognitive … testing of items in English and Spanish
• Field testing
• Construction of composite measures
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www.ahrq.gov/funding/grantee-profiles/grtprofile-leiferman.html
May 01, 2024 - Developing and Implementing Educational Resources to Address Perinatal Mental Health
Jenn Leiferman, Ph.D. Chair and Professor University of Colorado-Denver Jenn Leiferman, Ph.D. “Since early in my research career, I have been focused on what we could do to ensure that every child has the best possible start in…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv.html
June 01, 2010 - measures: bladder incontinence; skin ulcers; Activities of Daily Living (ADLs); locomotion in home; cognitive … items added for the Uniform Reporting System
Functional abilities (multiple dimensions, including cognitive
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact-references.html
July 01, 2024 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. … Sources of variation in primary care clinical workflow: implications for the design of cognitive support … Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact4.html
July 01, 2024 - Research has found that clinicians experience incredible rates of stress and burnout as a result of the cognitive
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact2.html
July 01, 2024 - from initial patient presentation to the final diagnosis, and can stem from multiple sources such as cognitive
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/DiagnosticSafety-flier.pdf
November 01, 2024 - Centers of Excellence focusing on better characterizing
sources of diagnostic error and developing and testing … Physician cognitive processing as a
source of diagnostic and treatment disparities in coronary heart
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
July 01, 2023 - Checklists are cognitive aids that—
Reduce slips that occur due to lapses in concentration, distractions … Use of cognitive aids, such as checklists.
Communication with rapid responders. … Use of cognitive aids.
Communication with rapid responders. … Cognitive aids such as checklists, algorithms, or protocols, may improve team response to cord prolapse … Use of cognitive aids.
Communication with rapid responders.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital_survey_composites-spanish.pdf
October 01, 2009 - Westat conducted cognitive interviews to pretest the Premier translation
and made some revisions. … A group-level model of safety climate: Testing the effect of
group climate on microaccidents in manufacturing
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/MeasureDx-guide.pdf
July 01, 2022 - Diagnostic errors are
major contributors to patient harm, but their complexity and intertwined
cognitive … Understanding
the “why” issues requires considering both the
system-related and cognitive elements … A taxonomy that distinguishes the major cognitive
and system-related root causes can also be consulted … categories
Modified
fishbone diagram
for diagnostic
errors50
Identify system-
related versus
cognitive … constraint
Equipment/environment
(Re)-Design
Strong actions
Moderately strong actions
Checklists/cognitive
-
www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
July 01, 2022 - Diagnostic errors are
major contributors to patient harm, but their complexity and intertwined
cognitive … Understanding
the “why” issues requires considering both the
system-related and cognitive elements … A taxonomy that distinguishes the major cognitive
and system-related root causes can also be consulted … categories
Modified
fishbone diagram
for diagnostic
errors50
Identify system-
related versus
cognitive … constraint
Equipment/environment
(Re)-Design
Strong actions
Moderately strong actions
Checklists/cognitive
-
www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/schiff-summit2016.pdf
January 01, 2013 - cases
Schiff Arch Intern Med 2009
What went wrong: DEER Taxonomy Localization
8
Art Elstein
Cognitive … negative mammogram and/or ultrasound
• Atypical presentation
• Addison’s disease presenting with cognitive
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www.ahrq.gov/ncepcr/care/coordination.html
November 01, 2024 - Care Coordination
Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicate…
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www.ahrq.gov/sites/default/files/publications/files/simulproj11.pdf
June 30, 2014 - The research team will use
simulation and cognitive systems
engineering methods to design and test
prototype … AHRQ grant HS20339; Project period
May 1, 2011 – April 30, 2014
Uncontrolled variability in diagnostic
testing
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
September 01, 2022 - reflection, surveillance, and critical thinking to improve diagnostic performance and mitigate detrimental cognitive
-
www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
January 01, 2025 - department (ED) by a hazardous decision-making
environment fraught with time pressure and excessive cognitive … We examined testing outcomes at three EDs
within our health system between March and June 2020. … Rapid molecular testing was implemented in the ED alongside standard platform testing, with rapid
tests … We
found that, compared to standard testing, rapid testing significantly reduced the median time uninfected … Targeted rapid testing for
SARS-CoV-2 in the emergency department is associated with large reductions