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www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdf
January 01, 2025 - When diagnostic testing leads to harm: a new outcomes-based
approach for laboratory medicine. … Cognitive debiasing 1: origins of bias and theory of debiasing. … Cognitive debiasing 2: impediments to and strategies for change.
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www.ahrq.gov/sites/default/files/2025-04/newman-toker2-report.pdf
January 01, 2025 - has since been used to facilitate patient interaction with their medical records,21,22 to complete testing … Of this latter group, 76% had either vision,
cognitive, or motor problems as their reasons for needing … Subjectively quantified Maddox rod testing improves diagnostic yield over alternate
cover testing alone … The importance of cognitive errors in diagnosis and strategies to minimize them. … Feasibility of computerized psychological testing with psychiatric outpatients.
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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/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Gavin.pdf
January 01, 2001 - Inclusion criteria were cognitively intact or mild cognitive impairment (based on
MDS scores), use of … Safe Wheelchair Seating
129
recording of data from the MDS, including diagnosis, cognitive status … Conclusion
With further development and testing, the REAPS may offer potential as a
screening tool
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
May 01, 2017 - Cognitive psychology classifies tasks as either
involving schematic behavior or attentional
behavior … Checklists
are cognitive aids that have numerous
practical benefits, including reducing slips that … • Cognitive aids such as checklists,
algorithms, or protocols may improve
clinical team response … • To reiterate, cognitive aids support
standardization and a shared mental
model. … Staff can increase situational awareness by
using cognitive aids, such as checklists, of
maternal and
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www.ahrq.gov/patient-safety/reports/hotline/intro1.html
May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient … Introduction
Previous Page Next Page
Table of Contents
Developing and Testing the Health … No implementation recommendations were made other than strongly encouraging pilot development and testing … recommendations for expansion of such a system (or systems) nationwide, based on the results of the prototype testing … groups to identify important domains and language to be included in the event reporting form and used cognitive
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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
July 18, 2008 - Despite the seemingly esoteric view of cognitive failures, often problems seen in offices and
clinics … Patients may not seek
care in a timely manner; system issues can delay appointments, testing, or notification … along a potentially convoluted continuum of care (e.g., patient to
primary care provider to diagnostic testing … affected is the delivery of preventive services, such as mammograms, PAP smears,
fecal occult blood testing … The importance of cognitive errors in
diagnosis and strategies to minimize them.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/valuewebcast-sorrarev.pdf
February 01, 2018 - Value and Efficiency Supplemental Items for Hospitals and Medical Offices - SORRA
Value & Efficiency Survey Item
Development and Pilot Test Results
Joann Sorra, PhD
Project Director
User Network for Surveys on Patient Safety
Culture™ (SOPS™)
Westat, Rockville, MD
11
AHRQ Surveys on Patient Safety Culture
Surve…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/simulation/simulation-issue-brief.pdf
July 01, 2024 - Examples of barriers included difficulty managing
cognitive aids while wearing personal protective … More than half (6 of 11) reported latent safety threats
involved a cognitive aid. … Hazards embedded in the
cognitive aids included recommending an incorrect
dose or route for epinephrine … To Test Systems and Prepare Staff for a New Hospital Transition
Simulation-Based Clinical Systems Testing … Reliability and validity testing of the Creighton
Competency Evaluation Instrument for use in the NCSBN
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nemeth_116.pdf
April 27, 2008 - Copyright © 2008 Cognitive Technologies Laboratory. … Cognitive
systems engineering. New York: Wiley; 1994.
9. Cook R. … Joint cognitive systems:
Patterns in cognitive systems engineering. … Discovering
healthcare cognition: The use of cognitive artifacts to
reveal cognitive work. … Cognitive properties
of a whiteboard: A case study in a trauma centre.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
May 05, 2008 - care, and trauma teams have
employed simulation training with a positive effect on procedural and cognitive … It appears that human patient simulation is
effective in developing the cognitive, procedural, communication … testing. … Portable
advanced medical simulation for new emergency
department testing and orientation. … Cognitive-behavioral models
of social anxiety disorder.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
May 01, 2017 - Electronic
Fetal Monitoring
6
Safe EFM Tool
Purpose
Who should use
How to use
Key safety elements
Sample cognitive … Perinatal Care
Electronic
Fetal Monitoring
11
Key Safety Elements: Create Independent Checks
Providing cognitive … aids for standard EFM terminology and interpretation at the point of care
A sample cognitive aid using … and communication related to—
Situational awareness;
Ability to get additional help quickly;
Use of cognitive
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
April 07, 2008 - Broadly titled, these focus areas are
(1) cognitive simulation, (2) informatics, (3) “smart image,” … Cognitive Simulation
As new surgical technologies and techniques emerge, patients are often torn between … In particular,
cognitive simulation can provide clinicians with the opportunity to rehearse and explore … Given the effect the development of a cognitive simulator can make in regard to training and
patient … This multivariate cognitive simulation possesses the ability to grow, change, and
experience biologic
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
September 01, 2021 - treatment, and
Inadequate documentation (poor charting or failure to chart) of risk factors. 2
Cognitive
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www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
January 01, 2024 - Circadian and sleep/wake dependent aspects of subjective
alertness and cognitive performance. … Interactive mathematical models of subjective alertness and
cognitive throughput in humans. … Cognitive Function Following Acute
Sleep Restriction in Children Ages 10-14. Sleep 1980;21(8):861-8. … Applied Cognitive Psychology
1995;9(1):21-40.
(45) Brunner DP, Dijk DJ, Borbély AA. … Cognitive performance and reverie during the hypnopompic state.
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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/2024-07/col-report.pdf
January 01, 2024 - Conduct usability testing among patients and clinicians to guide its development
Aim #2: Assess the … In the modified aim, instead of
testing the validity and reliability of the Website on a cohort of 64 … We conducted a first round of paper
prototype testing, as detailed below. … Paper Prototype Usability Testing (2009-2010)
During paper prototype testing, done under the revised … menopausal counseling or annual physical exam
Exclusion criteria:
Inability to give informed consent
Cognitive
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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