Application of Aviation Risk Management Policy in Medical Error Cases at King Khalid University Hospital

Abstract

Abstract Objectives: Cognitive errors are believed to be responsible for the majority of medical errors in clinical practice. We set to identify the prevalence and the types of cognitive errors among cases reviewed by the Morbidity and Mortality (M and M) Committee at King Khalid University Hospital (KKUH). Methods: A cross-sectional, descriptive study conducted at KKUH, in Riyadh, Saudi Arabia from January 2017 to December 2019. All consecutive cases of adult patients that have had a full review by the M and M committee were included. We applied the adapted (aviation risk management criteria to medicine) to detect any cognitive error among our cases. The cases were classified into three classes based on the number of present errors (A; 3 or more errors, B; 2 errors, and C; 1 error). Descriptive statistics (frequencies and percentages) were used to describe the categorical study variables. Results: A total of 16 cases were included in this analysis. Eight cases (50%) fulfilled the criteria for category “A” (3 or more cognitive errors). Cases categorized as “B” with 2 errors was seen in 43.8% and cases categorized as “C” with 1 error was seen in 6.2% of cases. The most commonly observed errors were diagnostic flaws such as diagnostic errors in the face of patients’ symptoms. Conclusion: We used the aviation risk management approach to identify cognitive errors in medical cases. We observed that ≥3 errors were more prevalent in the reviewed cases, and the majority of these errors were due to diagnostic flaws.