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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
June 02, 2025 - Prologue—Volume 2—Systems Thinking and Patient Safety
1
Prologue
Systems Thinking and Patient Safety … However, systems thinking does not come naturally—especially to health care
professionals. … As a result, while systems thinking enables new and productive approaches to
improving patient safety … What are the human vulnerabilities with
respect to our thinking, emotions, and actions? … We hope these new pathways of thought
will enable us to meet our obligation in health care to “first
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www.ahrq.gov/patient-safety/settings/hospital/match/table-3.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Table 3: Critical … Thinking Process to Identify and Clarify Discrepancies
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Table of
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www.ahrq.gov/patient-safety/settings/hospital/match/table-1.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Table 1: Critical … Thinking Process to Identify and Clarify Discrepancies
Previous Page Next Page
Table of
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www.ahrq.gov/es/patient-safety/settings/hospital/match/table-3.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Table 3: Critical … Thinking Process to Identify and Clarify Discrepancies
Previous Page Next Page
Table of
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www.ahrq.gov/es/patient-safety/settings/hospital/match/table-1.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Table 1: Critical … Thinking Process to Identify and Clarify Discrepancies
Previous Page Next Page
Table of
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/new_model_thinking.pdf
February 01, 2014 - A New Model of Thinking in Clinical Preventive Services
ACHIEVEMENTS … IN PREVENTION
A New Model of Thinking in Clinical Preventive Services
The Harms of Screening: an … articleid=1785201
ACHIEVEMENTS IN PREVENTION A New Model of Thinking in Clinical Preventive Services
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
May 01, 2024 - diagnostic reasoning. 5,6 Diagnostic reasoning is the process by which a clinician uses medical knowledge, critical … thinking, and experience to gather, integrate, and interpret clinical information. … reduces decision-making flexibility, 11 is associated with task errors, 12 and can promote default thinking … rather than conscious and analytical thinking. 13 However, CLT as it applies to diagnostic accuracy
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www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
January 01, 2025 - Module materials:
• Module Overview – Describes the focus of the module as application of critical thinking … • Applying Critical Thinking – Case-based training materials to support the development of
expertise … Thinking Skills Coverage – Training and self-study materials
o Homebound Status – Training and self-study … Agency Self Assessment† NA NA 91.8% 98.2%
Critical Thinking Skills Development 97.7% 98.4% 94.2% 97.6% … Application of Critical Thinking Skills 93.1% 90.1% 89.7% 91.9%
Home Health Benefit – Homebound
Status
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
May 01, 2024 - Cognitive Load and Dual-Process Thinking Cognitive load also directly impacts dual-process thinking. … The dual processing model of cognition posits two main types of thinking processes. … Cognitive load directly affects clinicians’ ability to engage in dual-process thinking. … If extrinsic load is low, both type 1 and type 2 thinking can occur. … decreases due to the cognitive bandwidth required for this type of thinking.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
September 01, 2022 - If not, have you communicated your thoughts/questions to them? … What tools do you have to help you organize your thoughts/findings (e.g., SBAR)? … Use reflection, surveillance, and critical thinking to improve diagnostic performance and mitigate detrimental
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/pocket-card.pptx
June 02, 2025 - (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … in severity)
□ Inattention (difficulty focusing and cannot maintain attention)
□ Disorganized thinking … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from … (thinking is incoherent or hard to follow) OR
Altered level of consciousness (change is different from
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - Team members need to alternate between convergent and divergent thinking. … Divergent thinking
Divergent thinking includes brainstorming and possibility thinking to explore questions … Convergent thinking
Convergent thinking asks the team to confer about all the potential problems that … Slide 17: Summary
Say:
To review the main components of this module, consider these thoughts:
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2sess2.html
October 01, 2014 - Critical thinking skills.
Patient safety. … It makes for familiar expectations for everyone, and it encourages critical thinking skills.
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www.ahrq.gov/patient-safety/settings/hospital/match/chapter-5.html
July 01, 2022 - The thought process or "critical thinking" involved with performing medication reconciliation. … Table 3 helps everyone performing medication reconciliation walk through the "critical thinking process … The critical thinking required for identifying intended (i.e., purposeful) vs. unintended medication
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www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-5.html
July 01, 2022 - The thought process or "critical thinking" involved with performing medication reconciliation. … Table 3 helps everyone performing medication reconciliation walk through the "critical thinking process … The critical thinking required for identifying intended (i.e., purposeful) vs. unintended medication
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www.ahrq.gov/talkingquality/resources/cognitive/index.html
September 01, 2019 - Cognitive testing is an interview method for investigating the thought processes and reactions that people … As the respondents look through the report, the interviewer prompts them to share their thoughts and … Listening as Respondent "Thinks Out Loud:" The interviewer asks respondents to share every thought and … opinion as they go through the document, a process known as "thinking out loud." … ask "Tell me what you are thinking" or "What are you thinking right now?"
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
May 01, 2017 - Team members need to alternate between convergent and divergent thinking. … Divergent thinking
Divergent thinking includes brainstorming and possibility thinking to explore questions … Convergent thinking
Convergent thinking asks the team to confer about all the potential problems that … Slide 16
SAY:
To review the main components of this module, consider these thoughts:
Every system
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
May 01, 2024 - diagnostic reasoning.5,6 Diagnostic reasoning is the process by which a clinician uses medical
knowledge, critical … Cognitive Load and Dual-Process Thinking
Cognitive load also directly impacts dual-process thinking. … If extrinsic load is low, both type 1 and type 2 thinking can occur. … A few thoughts on cognitive overload. … vignette-based as-
sessment under testing conditions designed to encourage either automatic or analytic thought
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
May 01, 2017 - Team members need to alternate between
convergent and divergent thinking. … Divergent thinking
Slide 14
http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit … includes brainstorming and
possibility thinking to explore questions such
as—
• What is the patient … Convergent thinking
Convergent thinking asks the team to confer
about all the potential problems that … Slide 16
SAY:
To review the main components of this
module, consider these thoughts:
• Every system
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-selfpaced-roadmap.pdf
February 01, 2022 - Roadmap:
TeamSTEPPS® for Diagnosis Improvement
Become familiar with
foundational concepts
Prime your thinking … Review the Facilitator’s Guide, which includes probing
questions to stimulate thinking about teamwork … Do you have thoughts about why
or why not?