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psnet.ahrq.gov/training-catalog/safety-pediatric-dental-care
August 10, 2025 - It is based on the latest knowledge on safety in healthcare, while also offering resources specific to
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psnet.ahrq.gov/node/851365/psn-pdf
July 27, 2023 - advancing-diagnostic-excellence-maternal-health-care
These free workshops discussed current challenges in diagnostic excellence, identifications of knowledge
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psnet.ahrq.gov/node/73123/psn-pdf
April 01, 2020 - Quality and
Research funded research and implementation projects supporting evidence creation and knowledge
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psnet.ahrq.gov/node/865348/psn-pdf
January 01, 2023 - learning-health-systems
The learning health system model centers on the purposeful, systematic use of internal data and
knowledge
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - There was no validated fall prevention knowledge test at that time, so we developed one. … Most nurses who take this fall knowledge test before training fail it. … that even when individuals fail the knowledge test, they still score high on the efficacy scale. … The lesson is that nurses should take the fall prevention knowledge test to identify gaps in their knowledge … As patients’ knowledge of their fall risk factors and plans improves, fall rates decrease.
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - There was no validated fall prevention knowledge test at that time, so we developed one. … Most nurses who take this fall knowledge test before training fail it. … that even when individuals fail the knowledge test, they still score high on the efficacy scale. … The lesson is that nurses should take the fall prevention knowledge test to identify gaps in their knowledge … As patients’ knowledge of their fall risk factors and plans improves, fall rates decrease.
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psnet.ahrq.gov/node/867042/psn-pdf
October 30, 2024 - health systems (LHS) build functions, networks, and processes to use data, information,
evidence, and knowledge
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - The efficacy of self-check is limited by time pressure and by asymmetric knowledge—individuals in the … study, knowing that CT is the preferred imaging approach for acute stroke, but lacking the clinical knowledge … Both individuals have detailed knowledge, but it is asymmetric, involving different aspects of the patient's … Successive checks in medicine can also be limited by asymmetric knowledge and by the explicit or implicit … team members are empowered to speak out, decreasing the power hierarchy and lessening asymmetry in knowledge
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psnet.ahrq.gov/issue/awareness-and-use-cognitive-aid-anesthesiology
January 05, 2017 - September 9, 2011
Assessment of healthcare professionals' knowledge of managing emergency … March 1, 2011
Knowledge-based errors in anesthesia: a paired, controlled trial of learning
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - Robust research data now
exist showing that physicians, like all people, do not self-assess their knowledge … step is often skipped, especially by experienced physicians,
who may be overly confident in their knowledge … experienced in another discipline that uses toxic, high-risk medications believes he or she has
the knowledge … instituted maintenance-of-certification (MOC) programs that require
physicians to self-assess their knowledge … Who can I consult to
help me acquire new knowledge and skills?
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psnet.ahrq.gov/node/844778/psn-pdf
September 18, 2019 - assessing-clinical-reasoning-targeting-higher-levels-pyramid
Effective decision-making relies on practice and knowledge
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psnet.ahrq.gov/node/73226/psn-pdf
May 05, 2021 - doctors-were-sure-they-had-covid-19-reality-was-worse
Diagnosis can be challenged by cognitive bias, fatigue, and lack of knowledge
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - the background may compare entered data with information in electronic medical
records or clinical knowledge … and intending for the patient’s previous regimen to be discontinued)
but apparently had inadequate knowledge … This tacit knowledge (not explicit but implicitly acquired through the
knowledge of the domain) may … however, that order entry systems may create possibilities for error if users
have incomplete conceptual knowledge
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - frequency than other occupational groups.( 11 )
Reasons for Presenteeism: Logistics, Culture, and Knowledge … health care worker presenteeism occurs are complex and include a combination of logistic, cultural, and knowledge-based … and it is not always clear what is "too sick" to work or truly risky for patients.( 6 ) The lack of knowledge … Reducing it will require attention to all drivers of the problem: logistics, culture, and knowledge. … A survey of physician and nurse knowledge, attitudes, and practices around injection safety.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
September 01, 2003 - Practitioner Factors
Knowledge, skills, rules
Attention
Strategy
Motivation & attitude
Physical … Commitment
Every team member is committed to attaining the goals
Competence
Every team member has knowledge … Key Components of Clinical Competence
Knowledge application
Problem-solving skills
Decision-making … Key Components of Clinical Competence
Situation awareness
Preparedness
Knowledge alone is not sufficient
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - major categories that contributed to the error (see next slide)
*
Wrong regimen
ordered
Handoffs
Knowledge … Care location
Fellow lack of knowledge about
penile Ca regimens
Rare cancer: inpatient attending … lack of content expertise
Resident and team
attending lack of
oncology knowledge
Outpatient
oncologist … Case
A standardized process may have prevented this error
Unfortunately, because it arose from a knowledge
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psnet.ahrq.gov/node/764410/psn-pdf
March 02, 2022 - improving-diagnostic-performance-through-feedback-diagnosis-learning-cycle
https://psnet.ahrq.gov/issue/teaming-how-organizations-learn-innovate-and-compete-knowledge-economy
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psnet.ahrq.gov/node/836871/psn-pdf
April 06, 2022 - areas of focus to drive
improvement: time constraints, increased care options, information technology, knowledge
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psnet.ahrq.gov/node/839330/psn-pdf
November 02, 2022 - diagnosis-reducing-errors-and-improving-quality
The task of performing a safe diagnosis has gone beyond the use of technical skill and knowledge
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psnet.ahrq.gov/node/72686/psn-pdf
January 27, 2021 - illustrates how bias and other reasoning flaws are more likely to result in
diagnostic errors than a lack of knowledge