Aviation model cognitive risk factors applied to medical malpractice cases.

OBJECTIVE Aviation accidents have been reduced substantially by training pilots to avoid high-risk behaviors caused by cognitive errors. To determine whether similar cognitive cause factors or errors are involved in medical malpractice cases, and to evaluate the reliability of identifying such factors, physicians reviewed state and federal malpractice cases in a legal database. METHOD Reviewing physicians evaluated 30 cases meeting inclusion criteria from state and federal malpractice cases for the year 2004 in the 8th US Circuit Court of Appeals region, using criteria for cognitive factors derived from aviation. The cases were categorized into three classes based on the degree of agreement between the reviewers. The results as to prevalence of the factors and reliability of identifying the factors were then analyzed statistically. RESULTS Fifty-nine percent of the cases met criteria for strong and good correlation with the factors. Cognitive factors involving IMSAFE (illness, medications, stress, alcohol, physiogical (f), and emotional) and medical team management/leadership can be reliably identified. Other factors, such as hazardous attitudes and loss of situational awareness, were identified with minimal reliability. CONCLUSION The aeronautical cognitive causative approach can be translated into a medical approach to reliably identify cognitive causes of errors in a significant proportion of medical malpractice cases from a legal database.

[1]  Adrian F. Ashman,et al.  Aeronautical decision-making , 1986 .

[2]  A. Wall,et al.  Book ReviewTo Err is Human: building a safer health system Kohn L T Corrigan J M Donaldson M S Washington DC USA: Institute of Medicine/National Academy Press ISBN 0 309 06837 1 $34.95 , 2000 .

[3]  G E Fryer,et al.  A preliminary taxonomy of medical errors in family practice , 2002, Quality & safety in health care.

[4]  T A Brennan,et al.  Relation between negligent adverse events and the outcomes of medical-malpractice litigation. , 1996, The New England journal of medicine.

[5]  C. Wild.  Building a safer health system , 2001 .

[6]  Richard S. Jensen,et al.  Aeronautical Decision Making for Instrument Pilots. , 1987 .

[7]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[8]  Vimla L. Patel,et al.  Toward An Action Based Taxonomy of Human Errors in Medicine , 2019, Proceedings of the Twenty-Fourth Annual Conference of the Cognitive Science Society.

[9]  R. Phillips,et al.  Learning from malpractice claims about negligent, adverse events in primary care in the United States , 2004, Quality and Safety in Health Care.

[10]  D. Bates,et al.  Effect of reducing interns' work hours on serious medical errors in intensive care units. , 2004, The New England journal of medicine.

[11]  Richard S. Jensen,et al.  AERONAUTICAL DECISION MAKING FOR COMMERCIAL PILOTS , 1988 .

[12]  S. Dovey,et al.  Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. , 2002, The Journal of family practice.

[13]  Richard S. Jensen.  Aeronautical Decision Making - Cockpit Resource Management , 1989 .

[14]  Russell S Lawton,et al.  Aeronautical Decision Making for Student and Private Pilots. , 1987 .

[15]  F A Sloan,et al.  Factors that prompted families to file medical malpractice claims following perinatal injuries. , 1992, JAMA.