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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - Laboratory testing showed only abnormal transaminases. … This case is demonstrative of cognitive errors associated with lack of knowledge of the features of, … Many of these errors are best categorized as cognitive and relate to a clinician’s decision-making, … testing those with risk factors or symptoms that suggest SEA. … Cognitive errors in diagnosis: Instantiation, classification, and consequences.
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - Cognitive errors are all too common in medical decision-making. … Learn to use cognitive forcing strategies to reduce diagnostic error ( 23 ); understand the common cognitive … Cognitive errors in diagnosis: instantiation, classification, and consequences. … Cognitive forcing strategies in clinical decision making. … April 3, 2018
When diagnostic testing leads to harm: a new outcomes-based approach for
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs022087-singh-final-report-2018.pdf
January 01, 2018 - Methods: We conducted critical decision method-based cognitive task-analysis of providers who
ordered … Our specific aims were:
Aim 1: To understand the cognitive factors that affect the task of test result … Aim 3
Using our cognitive walkthrough, work system maps, information obtained through rapid
assessment … Aim 2
The cognitive walkthrough method included how clinical content interacts with the user
interface … Similarly, cognitive walkthroughs did not incorporate any non-standard procedures (e.g., “work
around
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cdsic.ahrq.gov/sites/default/files/2024-09/Final_MO%20PC%20CDS%20User%20Guide%20(1)_0_0.pdf
January 01, 2024 - ,
technical acceptability testing, and initial usability testing. … report if they conducted activities related to assessing usability of the designed tool,
including cognitive … • Results of cognitive task load assessments. … • Approaches used to conduct PC CDS prototype testing (number of
testing rounds, testing participants … Working minds: A practitioner's guide to cognitive task analysis.
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digital.ahrq.gov/sites/default/files/docs/citation/k01hs019001-wen-final-report-2017.pdf
January 01, 2017 - literature review, web portal survey, patient and provider interviews,
health literacy evaluation, cognitive … user testing and usability testing. … Phase 4 included both cognitive user and usability testing for
system refinement to maximize MyHealthPortal … at FCCC; 3) able to
communicate in English; 4) able to give consent; 5) no evidence of significant cognitive … Cognitive-behavioral
intervention to promote smoking cessation for pregnant and postpartum inner city
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/annlrpt2013%20(4).pdf
November 01, 2013 - Screening for Cognitive Impairment and Dementia
2. … for Clinical Preventive Services: Focus on Older Adults .........................14
Screening for Cognitive … Screening for Cognitive Impairment and Dementia
Dementia (cognitive impairment that is severe enough … Milder forms of cognitive impairment are even more common and
may affect as many as 15 to 25 percent … The Task Force has found several important gaps in the evidence on screening for cognitive impairment
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/obstructive-sleep-apnea-in-adults-screening
March 04, 2021 - What are the harms associated with screening or subsequent diagnostic testing for OSA, including for … What are the barriers to undergoing diagnostic testing for OSA (e.g., availability of polysomnography … , ability to tolerate testing)? … How often do those barriers prevent completion of testing? … as incident atrial fibrillation), cerebrovascular events, incidence of heart failure, headaches, and cognitive
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www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/autism-spectrum-disorder-in-young-children-screening
February 16, 2016 - those based on applied behavior analysis have the highest-quality data supporting their effects on cognitive … in children, reported potential harms include misdiagnosis and the anxiety associated with further testing … after a positive screening result, particularly if confirmatory testing is delayed because of resource … Four RCTs reported cognitive and language outcomes for early intensive behavioral interventions delivered … Potential harms include misdiagnosis and the time, effort, and anxiety associated with further testing
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digital.ahrq.gov/ahrq-funded-projects/use-patient-buddy-application-disseminate-knowledge-prevent-readmission
January 01, 2023 - Due to patient cognitive dysfunction from the illness, caregiver involvement is essential to understanding … They were trained on entering medication adherence, daily sodium intake, vital signs, and weekly cognitive … User testing indicated that some patients found the data entry requirements to be too demanding, but
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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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www.ahrq.gov/ncepcr/reports/2024-annual-report/spotlight-s5-jih.html
May 01, 2024 - sharing of patient-reported outcomes (PROs)—such as symptoms of depression, anxiety, mood, sleep, and cognitive … The research team will conduct participatory design sessions, field testing, workflow prototyping, and … pilot testing of the app with patients, clinicians, and clinic staff.
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digital.ahrq.gov/ahrq-funded-projects/knowledge-engineering-decision-support-osteoporosis/annual-summary/2011
January 01, 2011 - They include process barriers, such as workflow and organization, and information and cognitive barriers … Specific cognitive barriers to identifying and treating osteoporosis include failure to identify that … The findings will inform the development and pilot testing of a new tool.
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs018205-kearns-final-report-2012.pdf
January 01, 2012 - Cognitive function. … Tortuosity in
movement paths is related to cognitive impairment. … A standard
procedure for using TURN180 Testing dynamic
postural stability among elderly people. … Tortuosity in
movement paths is related to cognitive impairment. … Path tortuosity and cognitive functioning.
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digital.ahrq.gov/ahrq-funded-projects/massachusetts-quality-e-measure-validation-study/annual-summary/2011
January 01, 2011 - The project included primary analyses with formal hypothesis testing and secondary analyses to identify … The patient survey instrument, including revisions based on feedback gathered from cognitive testing,
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs018420-post-final-report-2016.pdf
January 01, 2016 - This study compare d
cognitive and physical disability scores along with prognostic score to … health outcomes for geriatric patients
presenting to emergency departments (EDs) by developing and testing … was to improve geriatric
patient health outcomes presenting to EDs by developing, validating, and testing … We used Rasch techniques to derive
a better measure of functional and cognitive disabilities. … Health Service Uti l ization Access –including all-cause related
hospitalization, ED visits and testing
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digital.ahrq.gov/ahrq-funded-projects/evaluating-and-enhancing-health-information-technology-covid-19-response
December 31, 2024 - as containment strategies to prevent spread; preparation, such as ensuring sufficient supplies for testing … Model information workflow, employing cognitive engineering frameworks such as the Systems Engineering … benefit of full evidence-based research—to implement containment strategies, to ensure they had enough testing … They will then employ cognitive engineering frameworks such as the Systems Engineering Initiative for
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digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-support-population-based-clinical-practice/annual-summary/2012
January 01, 2012 - reporting system for pediatric and adult respiratory infections that captures routine microbiological testing … mentorships with experts in advanced epidemiologic and statistical methods, health services research, cognitive … what additional content and tools (e.g., patient education, ARI guidelines, information about viral testing … and deployed a mobile antibiogram application that provides the last full year’s data on antibiogram testing … They are currently testing the application and devising an evaluation plan.
Dr.
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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