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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Feldstein.pdf
January 01, 2004 - Alert discount usability testing
Discount usability testing can be used to evaluate computer applications … testing. … Discount usability testing served as an effective means of evaluating
our clinical alerts. … Think-aloud
approaches to cognitive assessment and the articulated
thoughts in simulated situations … Alert before and after usability testing
Figure 2. Sample final alert
Figure 3.
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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
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www.ahrq.gov/talkingquality/translate/scores/framing.html
March 01, 2016 - This reduces the cognitive burden on users, since they don’t have to keep reorienting themselves to look
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www.ahrq.gov/sops/news/previous-announcements.html
March 01, 2025 - Safety Supplemental Items for the Hospital SOPS To address emerging needs, AHRQ is developing and pilot testing
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-webcast-transcript.pdf
June 01, 2020 - After working through this process and doing the pilot
testing, we anticipate that this item set will … a "Does not apply/Don't know"
response option, rewording complex or difficult to translate items, testing … Gray, Slide 25
In 2017, after conducting rounds of cognitive testing of new survey items, we conducted … closely with AHRQ and the SOPS technical expert panel, we decided to
continue further development and cognitive … testing for HSOPS 2.0.
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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.pptx
May 01, 2017 - high-reliability professions
Health care errors are often slips rather than mistakes
Checklists are cognitive … and communication related to—
situational awareness,
ability to get additional help quickly,
use of cognitive … Safety
26
Key Safety Elements: Create Independent Checks
Increase situational awareness by using cognitive … of cervical balloon catheter
external cephalic version
amnioinfusion
placement of forceps or vacuum
Cognitive … 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/2024-01/robinson-papp-report.pdf
January 01, 2024 - PWH and chronic pain, we took an iterative approach including stakeholder input,
and development and testing … Use urine drug testing at least annually.
11. … 2) progress toward a pain treatment goal; 3) opioid side effects (constipation, nausea,
vomiting, cognitive … -
pharmacologic pain treatments, calculation of morphine equivalents (MME), interpreting urine drug testing … of past studies relied
exclusively on EHR-based outcomes such as MME and the presence of urine drug testing
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www.ahrq.gov/pqmp/implementation-qi/toolkit/antipsychotic/other-resources.html
September 01, 2021 - the importance of monitoring side effects when taking antipsychotic medications (i.e., need for lab testing … The Model for Improvement involves testing change ideas using Plan-Do-Study-Act (PDSA) cycles. … and/or vocational training programs may be indicated for some children or adolescents to address the cognitive
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter3tab3.html
June 01, 2014 - (not mutually exclusive): children with special health care needs; the frail elderly; persons with cognitive
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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/pqmp/measures/acute/chipra-208-fullreport.pdf
May 13, 2019 - reviews, of outcomes for babies born preterm versus
term, preterm infants had significantly lower cognitive … preterm
infants via parental education, family support, and pediatric follow-up have shown improved
cognitive … No reliability or validity testing was performed on
the imputed data. … Bhutta AT, Cleves MA, Casey PH, et al. cognitive and behavioral outcomes of school-aged
children who … Enhancing the development of low birthweight, premature
infants: Changes in cognitive and behavior over
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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/sites/default/files/2024-12/weinger2-report.pdf
January 01, 2024 - A Cognitive Task
Analysis (CTA) technique, the Critical Decision Method, was used during 1- to 2-hour … In-depth analysis of events, for
example, using cognitive engineering may be a useful adjuvant. … Thereafter, we expect this work to lead to
testing of key hypotheses in prospective studies, during … The data support a cognitive apprenticeship
model of new specialist physician training.
3. … Seamster TL, Redding RE, Cannon JR, Ryder JM, Purcell JA: Cognitive task analysis of
expertise in air
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf
December 01, 2014 - Discuss activity restrictions
Facilitate further diagnostic
testing
Facilitate further health care … Physical or Cognitive Impairment
Several studies identified impaired physical or cognitive function … controls (59% ED-made appointment vs. 37% controls).75 Appointments made for cardiac stress
testing … Emergency department patient compliance with followup for outpatient
exercise stress testing: a randomized … The effectiveness of a followup program at improving HIV
testing in a pediatric emergency department
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions7.html
June 01, 2023 - The cognitive imperative: thinking about how we think. Acad Emerg Med. 2000;7(11):1223-1231. … The importance of cognitive errors in diagnosis and strategies to minimize them. … Quantifying electronic health record data: a potential risk for cognitive overload. … Cognitive errors detected in anaesthesiology: a literature review and pilot study. … Cognitive interventions to reduce diagnostic error: a narrative review.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
April 01, 2025 - policy
· Training and education
· Additional study or analysis
Intermediate Actions
· Checklists or cognitive … or remove unnecessary steps
· Standardize equipment and process of care map
· New device usability testing
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www.ahrq.gov/talkingquality/distribute/placement/settings.html
January 01, 2023 - Settings: Finding the Audience for a Health Care Quality Report
Reconfirming Who Your Audience Is
Before you can identify appropriate settings, you need to have a clear and shared sense of the audience you are trying to reach. Assuming your resources are limited, you’ll probably need to set priorities within …
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www.ahrq.gov/sites/default/files/2024-10/klein-report.pdf
January 01, 2024 - Attention is commonly conceptualized as “energy” that is
available for cognitive information-processing2 … Doppler sonography (TCDS) has been used for
assessing BFV changes of the cerebral arteries during cognitive … Research has indicated that (1) BFV of the MCA increases as
participants engage in cognitive activities15 … The increased blood flow is triggered by cognitive task performance;
neural activity leads to increases … Transcranial Doppler ultrasonography monitoring of
cerebral hemodynamics during performance of cognitive
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
January 01, 2017 - Affective Bias
Cognitive Bias
What interventions work?
Decision support ?
Second opinions ? … Patient’s Clinical Course
SYSTEM
Me
Communication,
coordination, training,
policies, procedures
Cognitive
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
March 06, 2025 - Resuscitation Cart Medication Drawer
Researchers used human factors engineering principles and usability testing … • Hazard Assessment and Remediation Tool [HART] for Simulation-
Based Healthcare Facility Design Testing … pdf
Engineering Safe Practices Affinity Group
Page 12 of 17
• Task analysis, including cognitive … health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/cognitive-task-analysis