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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - This cognitive shortcut enables rapid decisions with negligible analysis but at the cost of critical … thinking and potential performance errors.
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - In thinking about the case, the intensivist recognized that she simply didn't have the time to think
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - They spent a little time talking with the patient and telling them what they thought might be going on … KH: You know, over the past year we've been paying more and more attention to telemedicine and thinking … We began by thinking EMS was a very important part of the emergency system.
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psnet.ahrq.gov/node/842769/psn-pdf
January 18, 2023 - Production pressure and its relationship to safety: a
systematic review and future directions.
January 18, 2023
Hashemian SM, Triantis K. Production pressure and its relationship to safety: a systematic review and
future directions. Safety Sci. 2023;159:106045. doi:10.1016/j.ssci.2022.106045.
https://psnet.ahrq.go…
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - forgettable (e.g., start over by taking your own history), allowing the brain to concentrate on higher-level thinking
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Even under the best circumstances, there are limits on human thinking and
the ability to be consistently
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Biases in the Diagnostic Process Clinician decision-making often relies on cognitive thought processes—called … It entails switching from “automatic thinking” (also called “intuitive” or System 1 reasoning ) to more … “reflective thinking” (also called “analytical” or System 2 reasoning), informed by communication
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psnet.ahrq.gov/issue/engaging-patient-observer-promote-hand-hygiene-compliance-ambulatory-care
September 02, 2020 - COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought
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psnet.ahrq.gov/issue/demonstrating-value-postgraduate-fellowships-physicians-quality-improvement-and-patient
November 04, 2015 - Interviewed mentors also generally thought the fellowships were important and the resulting research
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psnet.ahrq.gov/issue/interruptions-and-multi-tasking-moving-research-agenda-new-directions
March 23, 2011 - September 26, 2016
Momentary interruptions can derail the train of thought.
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - The major cause of the missed diagnosis of sepsis was thought to be the focus on tumor lysis syndrome … The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - was no pneumothorax from the line they had placed but did not “see” the retained sponge because they thought … February 1, 2003
Thinking in three's: changing surgical patient safety practices
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psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Unaware that any of the medications were duplicates, she thought she was taking exactly what her physician … 2003
Perspective
Establishing a Safety Culture: Thinking
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psnet.ahrq.gov/issue/medication-safety-program
November 30, 2023 - Multi-use Website
Medication Safety Program.
Citation Text:
Medication Safety Program. Atlanta, GA: Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/advancing-health-care-safety-all
July 19, 2024 - Fact Sheet/FAQs
Advancing Health Care Safety for All.
Citation Text:
Advancing Health Care Safety for All. Centers for Medicare and Medicaid Services. 2024.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - There was no reason why the system architect should have thought to tell us or even annotate the system
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psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
June 01, 2017 - Interestingly, when we tried to publish our findings in the BMJ, the paper was rejected because it wasn't thought … We thought, if it's a real quality of care issue, maybe we would see effects in indicators other than
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psnet.ahrq.gov/issue/racism-and-health
April 06, 2022 - Multi-use Website
Racism and Health.
Citation Text:
Racism and Health. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/patient-notification-toolkit
September 07, 2016 - Toolkit
Patient Notification Toolkit.
Citation Text:
Patient Notification Toolkit. Centers for Disease Control and Prevention; CDC.
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psnet.ahrq.gov/issue/rxawareness
September 07, 2016 - Multi-use Website
RxAwareness.
Citation Text:
RxAwareness. Centers for Disease Control and Prevention; CDC.
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