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psnet.ahrq.gov/innovations
February 26, 2025 - The PSNet Innovations page includes innovations developed, tested, and sustained within the past five … March 29, 2023
Cognitively impaired patients may be at increased risk of adverse … Library
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Cognitively
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psnet.ahrq.gov/issue/cognitive-biases-and-artificial-intelligence
March 27, 2024 - In this study, researchers tested AI models using clinical vignettes involving 10 cognitive biases.
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - Take-Home Points In the complex ICU environment, teams must recognize that their work is cognitively
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psnet.ahrq.gov/issue/cognitive-interventions-reduce-diagnostic-error-narrative-review
October 16, 2012 - biases that contribute to misdiagnosis, few interventions to address this problem have been formally tested … However, most of the proposed interventions have not been formally tested, and even fewer have evaluated
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psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - Diagnostic Errors
June 15, 2024
Diagnostic Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/diagnostic-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 20…
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psnet.ahrq.gov/issue/role-cognition-generating-and-mitigating-clinical-errors
January 07, 2015 - Review
Role of cognition in generating and mitigating clinical errors.
Citation Text:
Patel VL, Kannampallil TG, Shortliffe EH. Role of cognition in generating and mitigating clinical errors. BMJ Qual Saf. 2015;24(7):468-474. doi:10.1136/bmjqs-2014-003482.
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psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
June 21, 2016 - Study
Classic
Cognitive errors in diagnosis: instantiation, classification, and consequences.
Citation Text:
Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41.
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psnet.ahrq.gov/issue/detection-rates-mild-cognitive-impairment-primary-care-united-states-medicare-population
February 16, 2022 - Study
Detection rates of mild cognitive impairment in primary care for the United States Medicare population.
Citation Text:
Liu Y, Jun H, Becker A, et al. Detection rates of mild cognitive impairment in primary care for the United States Medicare population. J Prev Alz Dis. 2024;11:7–12…
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Test the patient for iron deficiency This patient should have been tested for iron deficiency. … by Mouth” sign should be prominently displayed at the bedside, and a wristband can also be used for cognitively … Patients with pica should be tested for iron deficiency and evaluated and treated for psychiatric comorbidities
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psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - Diagnostic Errors
Citation Text:
Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/print/pdf/node/838351
July 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Safety Improvement
Curated Library
Foundations
Improving Diagnosis in Health Care.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and
Medicine. Washington, DC: National Academies Press; …
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - self-monitoring functions so that we might recognize when we are at risk for being (or have already become) cognitively
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psnet.ahrq.gov/issue/situativity-family-social-cognitive-theories-clinical-reasoning-and-error
June 08, 2022 - Special or Theme Issue
Situativity: A Family of Social Cognitive Theories for Clinical Reasoning and Error.
Citation Text:
Situativity: A Family of Social Cognitive Theories for Clinical Reasoning and Error. Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.
Co…
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psnet.ahrq.gov/issue/more-words-interpersonal-communication-cognitive-bias-and-diagnostic-errors
March 11, 2013 - Commentary
'More than words' - interpersonal communication, cognitive bias and diagnostic errors.
Citation Text:
Dahm MR, Williams M, Crock C. ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. Patient Educ Couns. 2022;105(1):252-256. doi:10.1016/j.pec…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
April 17, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Safety Improvement
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/issue/developing-critical-thinking-skills-delivering-optimal-care
June 23, 2021 - Commentary
Developing critical thinking skills for delivering optimal care
Citation Text:
Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi:10.1111/imj.15272.
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