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Background Adverse events in the perioperative period remain frequent, occurring in about 30% of the hospital admission and may be avoidable in nearly 50% of cases. Improving safety needs a continuous assessment of the risk level. Material and methods Data from the MACSF-Sou medical insurance company, including all the statements declared by anaesthesiologists and intensivists, were analyzed retrospectively by three experts, senior anaesthesiologists, of the SFAR, the French society of anesthesia and intensive care ( Societe francaise d’anesthesie reanimation ) to describe the risk associated with regional anaesthesia. Results One hundred and sixty-four events were analyzed, involving young patients (mean age of 48.3 ± 15 years; sex ratio: 0.57). The most involved surgical specialties were: orthopaedic surgery (61%) and obstetric surgery (13.4%). Reported events were predominantly peripheral nerve injury (64.6%). Mechanical complications of puncture (pneumothorax, haemothorax, complications of axial punctures) accounted for approximately 15% of events, infection for 11%. The revelation was predominant in the postoperative course (137 cases, 83.6%), particularly after the release of the operating room in over 47% of cases, including 39 cases (22%) after discharge from the hospital. Conclusion Collaboration with insurance companies allows a relevant approach of the perioperative risk. In most cases, liability related to regional anaesthesia involved young patients in the perioperative course of scheduled surgery. One of the future challenges in managing, the anaesthetic and perioperative risks should be to invest more accurately the postoperative care both in the hospital or ambulatory settings.

To understand the mechanisms related to both the onset and correction of severe anaemia after orthopaedic surgery, we analysed all the full blood counts (FBCs) for patients on one orthopaedic ward during a one-year period in an academic hospital.FBCs were screened and the medical records of those patients for whom a postoperative haemoglobin (Hb) concentration below 8 g/dL was recorded at least once were reviewed. The onset of postoperative anaemia was determined by calculating the various time intervals delineated by surgery, the time at which the transfusion threshold was reached and the time at which the lowest Hb level (nadir) and transfusion (if any) occurred.A total of 6573 FBCs drawn from 1255 patients were screened. The medical records of 74 consecutive patients with at least one Hb value8 g/dL were analysed. The postoperative Hb nadir was 7.4 (± 0.6) g/dL (mean - SD). The medians (IQR 25-75) of the calculated intervals were: (surgery - nadir): 72 (48-144) h, (nadir - transfusion): 7 (5-21) h and (transfusion threshold - transfusion): 26 (11-51) h.Delayed transfusion (defined as12 hours between the time at which the transfusion threshold was reached and actual transfusion) was observed in 57% of severely anaemic patients after orthopaedic surgery.

Resume La prescription postoperatoire est un sujet a l’interface des actions des anesthesistes et des chirurgiens. Les enquetes de qualite montrent que les prescriptions postoperatoires ne sont pas toujours formalisees et securisees. Il existe de ce fait un risque iatrogene. La prescription des antalgiques, des antiemetiques, des antibiotiques, des anticoagulants, et de l’alimentation/hydratation doit faire l’objet d’une systematisation et s’inscrire dans le cadre de protocoles de soins.

Objective The aim of the study was to assess the effectiveness of a new methodological tool for the identification of corrective and preventive actions (CAPAs) after root cause analysis of health care-related adverse events. Methods From January to June 2010, we conducted a randomized controlled trial involving risk managers from 111 health care facilities of the Aquitaine Regional Center for Quality and Safety in Health Care (France). Fifty-six risk managers, randomly assigned to two groups (intervention and control), identified CAPAs in response to two sequentially presented adverse event scenarios. For the baseline measure, both groups used their usual adverse event management tools to identify CAPAs in each scenario. For the experimental measure, the control group continued using their usual tools, whereas the intervention group used a new tool involving a systemic approach for CAPA identification. The main outcome measure was the number of CAPAs the participants identified that matched a criterion standard established by eight experts. Results Baseline mean number of identified CAPAs did not differ between the two groups (P = 0.83). For the experimental measure, significantly more CAPAs (P = 0.001) were identified by the intervention group (mean [SD] = 4.6 [1.7]) than by the control group (mean [SD] = 2.8 [1.2]). Conclusions For the two scenarios tested, more relevant CAPAs were identified with the new tool than with usual tools. Further research is needed to assess the effectiveness of the new tool for other types of adverse events and its impact on patient safety.

In view of the recent evolution of military conflicts, particularly in the Afghan theater, and the conditions in which wounded warriors are managed in the field prior to hospitalization, the authors examine the technical specificities of medical teams, based on studies of avoidable mortality. War surgery has become a separate specialty, following the disappearance in France of the general surgical specialty, of which it was the military coun-terpart. The authors stress the role of hemorrhaging and its treatment, based on three strategies: damage control resuscitation, blood transfusion, and early evacuation within the "golden hour ". The French Armed Forces Health Service, in a new strategic plan, is refocusing its activity on war traumatology, through better education and training of medical-surgical teams and by opening up its scholarship structures to the French civilian public health service sector.

Objective To assess the psychometric properties of the French version of the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC) and study the hierarchical structure of the measured dimensions. Design Cross-sectional survey of the safety culture. Setting 18 acute care units of seven hospitals in South-western France. Participants Full- and part-time healthcare providers who worked in the units. Interventions None. Main outcome measures Item responses measured with 5-point agreement or frequency scales. Data analyses A principal component analysis was used to identify the emerging components. Two structural equation modeling methods [LInear Structural RELations (LISREL) and Partial Least Square (PLS)] were used to verify the model and to study the relative importance of the dimensions. Internal consistency of the retained dimensions was studied. A test–retest was performed to assess reproducibility of the items. Results Overall response rate was 77% ( n = 401). A structure in 40 items grouped in 10 dimensions was proposed. The LISREL approach showed acceptable data fit of the proposed structure. The PLS approach indicated that three dimensions had the most impact on the safety culture: ‘Supervisor/manager expectations & actions promoting safety’ ‘Organizational learning—continuous improvement’ and ‘Overall perceptions of safety’. Internal consistency was above 0.70 for six dimensions. Reproducibility was considered good for four items. Conclusions The French HSOPSC questionnaire showed acceptable psychometric properties. Classification of the dimensions should guide future development of safety culture improving action plans.

Objective To assess the impact of a vignette-based analysis of adverse events (AEs) on the safety climate (SC) of care units. Design Prospective, open, cluster (a unit) randomised controlled trial. Setting Eighteen acute care units of seven hospitals in France. Participants Healthcare providers who worked in the units. Intervention Vignette-based analyses of AEs were conducted with unit's providers once per month for six consecutive months. The AEs were real cases that occurred in other hospitals. The hospital risk manager conducted each analysis as follows: analysis of the immediate and root causes of the AE; assessment of the care unit's vulnerabilities and existing barriers in the occurrence of an identical AE and search for solutions. Main outcome measure SC was measured using the French version of the Hospital Survey on Patient Safety Culture questionnaire. The primary outcome was the difference in the 'Organisational learning and continuous improvement' dimension score, from before to after the analyses. Results Median participation rate in the analyses was 20% (range: 7-45%). Before intervention, the response rate to the SC survey was 80% (n = 210) in the intervention group and 73% (n = 191) in the control group. After intervention, it was 59% (n = 141) and 63% (n = 148), respectively. The dimension score evolved differently for the groups from before to after intervention (intervention: +10.2 points ±8.8; control: -3.0 points ±8.5, P = 0.04). Side effects were not measured. Conclusions Vignette-based analysis was associated with the improvement of the perception of participants regarding their institution's capacity for organisational learning and continuous improvement.

BACKGROUND: Safety rules continue growing rapidly, as if constraining human behaviour was the unique avenue for reaching ultimate safety. Safety rules are essential for a safe system, but their multiplication can have counterproductive effects. OBJECTIVE: To monitor, in an anaesthesia ward, compliance with a process-oriented safety rule, and understand barriers and facilitators which help and hinder physicians from following guidelines. METHODS: The rule stipulated that the day before surgery anaesthetists had to record in the patient's file the drugs to be used for the anaesthesia (induction, maintenance, airway control). Compliance was assessed before introduction of the rule, immediately after, at 6 months and at 12 months. All medical staff were blinded to the protocol. RESULTS: 717 patient records were included. The results showed an initial compliance with policy, reaching 86% for some items (never 100%). Reduction began within 6 months and returned almost to initial levels within a year. One individual showed poor compliance throughout the study but even initially compliant doctors experienced a reduction. Compliance was higher for complex surgery but lower for unscheduled surgery and when job pressure was greater. CONCLUSIONS: Compliance eroded over time. A major trigger of erosion seemed to be lack of continued compliance by a senior member of staff. Rules and procedures constitute fragile safety barriers, and it may be better to forego introducing a new safety rule if it is not considered as a priority by staff and is therefore vulnerable to sacrifice in case of conflict with competitive demands.

Hyperglycemia is significantly associated with increased mortality in critically ill patients and then, strict control of blood glucose (BG) concentration is important. Lowering of BG levels with intensive insulin therapy (IIT) was recommended in order to improve patient outcomes. But recently, some recent prospective trials failed to confirm the initial data, showing conflicting results (significantly increased mortality with IIT, more hypoglycemic episodes). So there is no consensus about efficiency and safety of IIT. Significant associations between glucose variability and mortality have been confirmed by several recent studies. A difference in variability of BG control could explain why the effect of IIT varied from beneficial to harmful. Managing and decreasing this BG variability could be an important goal of BG control in critically ill patients. Clinicians have to consider definitions, physiopathology and impacts of glucose variability, in order to improve patient outcomes.

Resume Contexte Parmi les incidents de la chaine transfusionnelle, l’erreur de destinataire est potentiellement dangereuse pour le receveur, pouvant conduire, entre autres, a un effet indesirable par incompatibilite dans le systeme ABO. Materiel et methodes Le groupe de travail « Analyse des causes racines » de la Commission nationale d’hemovigilance a elabore un document de recueil de ce type d’incident, et l’a teste sur un echantillon de 43 cas d’erreur de destinataire de concentres de globules rouges declares entre mars 2009 et fevrier 2010. Resultats Les etapes defaillantes sont nombreuses : 109 pour 43 declarations, soit 2,5 etapes defaillantes en moyenne par incident declare. Si elles peuvent avoir lieu precocement au stade de constitution du dossier transfusionnel ou de la prescription, elles sont beaucoup plus nombreuses aux etapes de delivrance, de reception dans le service clinique et enfin de controles pretransfusionnels au lit du patient. Les modalites de decouverte de la defaillance ne sont pas toujours decrites lorsque la transfusion a ete effective, mais elles le sont plus souvent lorsque la transfusion a pu etre evitee par une etape de controle efficace pour detecter la defaillance initiale. Cela permet une approche objective de l’efficacite des barrieres de securite transfusionnelle existantes. Sur cet echantillon, les controles ultimes au lit du patient (concordances des documents et utilisation de reactifs anti-A et anti-B) n’ont arrete que trois transfusions sur les 34 cas ou l’erreur n’avait pas ete detectee a une etape anterieure, montrant une efficacite comparable au controle a reception dans le service clinique. Conclusion Le document de recueil elabore servira au reseau d’hemovigilance afin d’analyser de facon plus approfondie les cas declares non seulement avec les concentres de globules rouges, mais egalement avec les concentres de plaquettes et les plasmas frais congeles, et donc de mieux comprendre l’erreur de patient destinataire de produits sanguins labiles pour tenter d’en ameliorer la prevention.

Since March 2003, military operations in Iraq "Operation Iraqi Freedom" (OIF) and in Afghanistan "Operation Enduring Freedom" (OEF), have made many wounded and killed in action (KIA). This article proposes to highlight the specific epidemiology of combat casualties, met in these both non-conventional and asymmetric conflicts. Personal protective equipments, Kevlar helmet and body armor, proved their efficiency in changing features of war injuries. Health Force Services organized trauma care system in different levels, with three main objectives: immediate basic medical care in battalion aid station, forward surgery and early aeromedical evacuation. The Joint Theater Trauma Registry (JTTR), a war injury registry, provides medical data, analyzed from the combat theater to the military hospital in United States. This analysis concluded that during modern conflicts, most injuries are caused by explosive devices; injuries are more severe and interestingly more specifically the head region and extremities than the trunk. Hemorrhage is the first cause of death, leading to the concept of avoidable death. Specific databases focused on mechanisms and severity of injuries, diagnostic and treatment difficulties, outcomes can guide research programs to improve war injuries prevention and treatment.

Context: Methods and tools which enabled healthcare organization for learning from adverse events focus mainly on reporting and analysis phases. However, formulating appropriate action plan is also a difficult phase that current methods do not help us with. Objective: To assess the effectiveness of a tool for structuring action plan for hospital risk managers. Method: A randomization procedure has been used to assign 56 voluntary hospital risk managers in two groups differing only by the use of the tool. Each group had to identify causes and formulate an action plan for two scenarios of adverse drug events successively. The first measure was realized without tool. In the second measure, only the intervention group used the tool. Results: The mean difference in the number of relevant actions proposed by participants between the two measures was statistically significant between the reference group (M = − 0.6, SD = 2.2) and the intervention group (M = 1.3, SD = 2.2), t(53) = 2.96, p = < .01). In a linear mi...

Background More attention should be paid to rare serious adverse events such as anaphylaxis to increase the safety of anesthesia. Objective To report the results of an 8-year survey of anaphylaxis during anesthesia in France. Methods Data from patients who experienced anaphylaxis between January 1, 1997, and December 31, 2004, were analyzed. Estimated incidences were obtained by combining this database with data from the French pharmacovigilance system by using a capture-recapture method. The number of patients exposed to the offending agents was obtained from data collected during the national survey of anesthesia practice. Results A total of 2516 patients was included. A diagnosis of IgE-mediated reaction was established in 1816 cases (72.18%). The most common causes were neuromuscular blocking agents ([NMBAs]; n = 1067; 58.08%), latex (n = 361; 19.65%), and antibiotics (n = 236; 12.85%). The median annual incidence per million procedures was higher for females 154.9 (5th-95th percentile, 117.2-193.1) than for males 55.4 (5th-95th percentile, 42.0-68.0). It reached 250.9 (5th-95th percentile, 189.8-312.9) for women in cases of allergic reactions to NMBAs. In children, a diagnosis of IgE-mediated reactions was obtained in 122 cases (45.9%). The most common causes were latex (n = 51; 41.8%), NMBAs (n = 39; 31.97%), and antibiotics (n = 11; 9.02%). In contrast with adults, no female predominance was observed. Conclusion The incidence of allergic reactions during anesthesia, estimated on a national basis, is higher than previously estimated. These results should be taken into account in the evaluation of the benefit-to-risk ratio of the various anesthetic techniques in individuals. The similar incidence of reactions according to sex before adolescence suggests a role for sex hormones in the increase of anaphylaxis observed in women.

La epidemiologia de la mortalidad y de la morbilidad en anestesia engloba cuatro conceptos: la mortalidad, la morbilidad, su relacion con la anestesia y tambien el analisis de las causas desencadenantes, favorecedoras o simplemente asociadas a estos eventos. Aunque la mortalidad apenas plantea problemas de definicion, la morbilidad es un concepto mas complejo. Puede englobar aspectos muy especiales como, por ejemplo, las cefaleas posraquianestesia o las nauseas y vomitos postoperatorios. El enfoque mas seguro plantea la morbilidad de forma mas global, clasificandola por orden creciente de gravedad y de frecuencia, y la cuestion de las complicaciones «pertinentes» respecto a la evolucion de los pacientes es fundamental para mejorar la seguridad anestesica. La evolucion de la epidemiologia de la mortalidad y de la morbilidad sirve de fundamento y de guia a la logica de las intervenciones realizadas en aras de la seguridad anestesica. De este modo, recientemente se han realizado dos estudios extensos en Francia que han permitido ilustrar la pertinencia de modificaciones amplias de las practicas profesionales realizadas basandose en las conclusiones del primer estudio. Esta cuestion de la disminucion de la mortalidad anestesica con el paso del tiempo siempre ha sido el objeto de debates alimentados por dos tipos de argumentos. El primero consiste en la dificultad que existe para comparar los estudios de metodologias diferentes y, sobre todo, realizados en periodos distintos. Aunque se debe ser prudente a la hora de comparar los resultados de estos estudios, hay que senalar que esta problematica sigue siendo una constante en el seguimiento de los indicadores de la seguridad de los sistemas. El segundo tipo de argumentos esta relacionado con la confusion existente entre la disminucion de la mortalidad y la evolucion de la seguridad anestesica. Aunque las tasas de fallecimientos relacionados con la anestesia no correlacionan directamente con el nivel de seguridad, es razonable pensar que, en los ultimos anos, la disminucion de la mortalidad anestesica se relaciona con una mejora de la seguridad.

Resume La notion de detrompage renvoie bien souvent a des dispositifs physiques qui empechent de realiser une action erronee. En anesthesie reanimation, on pense d’emblee aux prises specifiques des gaz medicaux. Plus generalement, le principe du detrompage est d’eviter une erreur. Il consiste a placer dans l’environnement immediat d’une action l’information necessaire a sa bonne realisation, plutot que dans la tete de l’acteur. Comme souvent en gestion des risques, le monde de la sante a beneficie de transferts de l’industrie. L’outil informatique revolutionne la notion de detrompage, initialement pensee sur des attributs physiques, en aeronautique et dans l’industrie automobile. Le detrompage peut porter sur la prevention, la detection, la limitation des consequences des erreurs. Les fonctions de contraintes sont des modes de detrompage qui bloquent une action erronee ou qui forcent une action vertueuse. Grout donne un petit moyen pour reconnaitre un systeme de detrompage : « s’il n’est pas possible de le photographier en action, ce n’est probablement pas un systeme de detrompage ».

In anesthesiology, rules, recommendations and protocols are used to coordinate behaviour in order to improve patient safety. In systems which have reached a high level of safety, migration is defined as a daily deviation of practices leading to a space of action which is different from the one defined by the rule. Our study assesses variation of behaviour before and after the introduction of a new safety rule in an anesthesiologist's team. The rule introduced by the chief of department makes it compulsory to plan and write the procedure during the pre-anaesthetic visit (day before surgery). Assessments of state before the rule, and of its implementation (immediately after introduction, 6 months later, 12 months later) were made from the anaesthetic files (n=907). Anaesthetists were blind to the study. Items linked to the rule are the inscription of the type of anaesthesia, hypnotic, opioid, muscle relaxant, hypnotic for maintenance, ways of controlling the upper airway and tube size, in the case of general anaesthesia. This study showed an erosion of the implementation six months later, with statistical significance at 12 months (p

Resume Le syndrome de Mendelson est une complication majeure de la pratique de l’anesthesie. Le present article presente les donnees detaillees concernant ce syndrome obtenues au cours de l’etude realisee conjointement par la Societe francaise d’anesthesie et de reanimation (Sfar) et le Centre d’epidemiologie sur les causes medicales de deces (CepiDC) sur la mortalite anesthesique. Les methodes et les principaux resultats des deux enquetes ont ete prealablement publies. Brievement, la premiere enquete (1996) a permis d’estimer le nombre annuel et les caracteristiques des anesthesies realisees en France (denominateur). La seconde enquete a consiste a recueillir des informations a partir des certificats de deces de l’annee 1999 (numerateur). Apres une analyse globale des deces en rapport avec l’anesthesie, une investigation complementaire a ete menee pour etudier en detail les deces en rapport avec un syndrome de Mendelson. Quatre-vingt-trois deces ont ete rapportes a un syndrome de Mendelson, soit un cinquieme des deces totalement ou partiellement imputables a l’anesthesie pour un taux annuel d’un pour 221 368 anesthesies generales, soit 4,5 × 10−6 (IC 95 % : 0,8 × 10−6–14 × 10−6). Il s’agissait de patients dans un etat clinique grave (ASA ≥ 3 : 92 %), tres âges et souvent operes dans un contexte d’urgence digestive. Deux deces sont survenus a l’occasion d’une coloscopie et aucun en situation obstetricale. L’inhalation est survenue a l’induction dans tous les cas, sauf un. L’analyse des pratiques retrouve une non-conformite aux regles dans la presque totalite des cas. Les anesthesistes–reanimateurs francais doivent s’engager de facon volontariste dans des actions de formation medicale continue sur ce theme, de facon a optimiser leurs pratiques.

Resume La France connait un bouleversement demographique avec le vieillissement de sa population. Ce vieillissement est lie au poids demographique des classes d’âge du baby boom et a l’amelioration de l’esperance de vie. Pour la profession anesthesique, la traduction est essentiellement une elevation de l’âge moyen de la population chirurgicale. L’impact de l’âge sur le risque anesthesique ne peut etre evalue qu’en tenant compte des comorbidites, des complications attendues pour chaque type de chirurgie et de la qualite des soins dispenses pour cette pathologie par etablissement. L’evaluation individuelle du risque anesthesique doit reposer sur des indicateurs simples, eprouves et reproductibles, tels l’âge et le score ASA, faisant appel aux scores de Lee et Brooks-Brunn pour les risques specifiques cardiaque et respiratoire.

Resume Introduction L’evaluation des soins postoperatoires repose principalement sur le signalement d’evenements indesirables graves (EIG). Nous proposons une autre approche et prenons comme exemple l’exploration du risque lie a l’anemie postoperatoire, situation qui parait regulierement associee aux deces imputables a l’anesthesie. Materiel et methode La procedure a consiste a extraire le fichier genere par l’automate du service de biologie en filtrant les donnees sur le critere « service demandeur » et a le fusionner avec la base de donnees anesthesique. Le service selectionne a ete le service de chirurgie orthopedique en raison d’une large prescription d’heparine de bas poids moleculaire rendant frequentes et regulieres les numerations-formules sanguines (NFS). Toutes les NFS prescrites en 2005 ont ete analysees. Des zones de risque croissant ont ete determinees en fonction de l’âge et de l’intensite de l’anemie. Les dossiers des patients exposes au risque le plus fort ont ete analyses. Resultats Les NFS de 691 patients ont ete analysees. Quarante et une (5,9 %) avaient au moins une mesure de l’hemoglobine (hb) inferieure ou egale a 8 g/dl. Une hb inferieure a 8 g/dl a ete observee chez 18 patients (2,6 %) sur deux NFS consecutives deux jours distincts. Huit (1,2 %) dossiers « a haut risque » ont ete identifies et analyses, permettant de retrouver six cas de non-transfusion et/ou un retard a la transfusion (14,6 % des anemies postoperatoires). Conclusion Une approche globale du risque d’exposition a l’anemie ainsi qu’une methode fiable de detection des EIG lies a l’hemorragie postoperatoire peuvent etre obtenues « a la sortie de l’automate ».

Resume Objectifs Evaluer la tenue du dossier d’anesthesie selon les criteres du referentiel d’evaluation des pratiques professionnelles propose en 2005 par le College francais des anesthesistes-reanimateurs (Cfar). Type d’etude Etude retrospective, multicentrique. Patients et methodes Cinquante dossiers anesthesiques tires au sort dans 64 etablissements d’Aquitaine ayant une activite de chirurgie avec hospitalisation complete. La base de sondage etait constituee des sejours de plus de 24 heures, survenus au cours du deuxieme semestre 2005 et comportant un acte chirurgical avec anesthesie, hors anesthesie locale isolee ou anesthesie peridurale lors d’un accouchement par voie basse. Ont ete recueillies les informations correspondant aux dix criteres d’evaluation definis par le Cfar et la Haute Autorite de sante. Pour chaque etablissement, un indicateur global a ete defini par la somme du nombre de criteres conformes divisee par la somme du nombre de criteres applicables pour chacun des 50 dossiers. Resultats Trois mille cent quatre-vingt-treize dossiers anesthesiques ont ete evalues. Le taux de conformite des criteres variait entre 1 et 92 % avec pour certains criteres une dispersion importante selon les etablissements. La tracabilite des conditions d’abord des voies aeriennes superieures, de la visite preanesthesique et des incidents/accidents perianesthesiques etait inferieure a 40 %. Le taux median de conformite de l’indicateur global dans les etablissements etait de 56 %. Conclusion Cette etude apporte des informations sur les qualites documentaires du dossier d’anesthesie et les pratiques en termes d’evaluation preoperatoire.

Lying between two traditions of thought, one of which states that rules must always be respected (Weber, 1921), and the other that they can never be respected, this research suggests a third possibility, a contingent approach that distinguishes two types of rules: complex ones that cannot be scrupulously respected, and basic ones that are supposed to be strictly observed. Since the first type has been extensively studied, most of this article is devoted to basic rules and how they can be managed. In connection with collaborative management research carried out in a hospital in Île-de-France, we studied three activities: monitoring of peripheral venous catheters, sorting of healthcare waste and costing of hospital stays. After analysing breaches of basic rules for these activities, we propose corrective action of various kinds according to function, level of innovation and level of application. Regarding the latter, we have applied the recommendation of Reason (1997) which involves dealing with the problem of non-compliance with rules at three different levels: the organisational, engineering and individual levels. Whereas interventions carried out at the individual level have been widely discredited by studies of complex technological systems, our research shows their value when the relative simplicity of the situation makes it possible to formulate basic rules. Based on the observations made before and after implementing our proposed actions, we suggest adopting an approach to managing breaches of basic rules that we describe as dialogical, involving two complementary and antagonistic aspects: an enabling aspect and a disciplinary aspect., Entre deux traditions de pensée qui posent, l’une, que la règle doit toujours être respectée (Weber, 1921), l’autre, qu’elle ne peut jamais l’être (Reynaud, 1993), la présente recherche suggère l’existence d’une troisième option, celle d’une approche contingente distinguant deux types de règles : les complexes qui ne peuvent être scrupuleusement respectées et les élémentaires qui sont censées être strictement observées. Le premier type ayant été amplement étudié, l’essentiel de cet article est consacré aux règles élémentaires et à leur mode de management. Dans le cadre d’une recherche collaborative à visée managériale menée au sein d’un hôpital francilien, nous avons étudié trois activités - la surveillance des cathéters veineux périphériques, le tri des déchets de soin et la cotation des séjours. Après avoir analysé les manquements aux règles élémentaires attachées à ces activités, nous avons proposé des actions correctrices variées en termes de fonction, de degré d’innovation et de niveau d’application. Sur ce dernier point, nous avons exploité la recommandation de Reason (1997) consistant à aborder le problème du non-respect des règles à trois niveaux différents : organisationnel, ingénierique et individuel. Alors que les interventions menées au niveau individuel ont été largement déconsidérées par les travaux portant sur les systèmes technologiques complexes, notre recherche montre leur intérêt, lorsque la relative simplicité de la situation permet d’énoncer des règles élémentaires. Sur la base des observations réalisées avant et après la mise en œuvre de nos propositions d’action, nous suggérons, pour gérer les manquements aux règles élémentaires, l’adoption d’une approche que nous qualifions de dialogique jouant sur deux registres complémentaires et antagonistes : habilitant et disciplinant.

International audience; French military hospitals: external operations’ impact on the organisationMilitary activities such as External Operations may explain the important financial deficit highlighted by Cour des Comptes’s audit of the French military hospitals. This paper offers an analysis of the impact of external operations on operating rooms and thus on revenues from surgical activity.The methodology of the study is both qualitative and quantitative. The qualitative analysis is based on 27 interviews of military healthcare professionals while a simulation of surgery production in two military hospitals offers a quantitative approach to evaluate the impact of external operations on surgical activity.The outcomes of the interviews and the comparison of the simulation of surgical care provision with and without external operations, show that external operations have a negative but highly variable impact on hospital productivity.The study highlights that some organisational strategies improve hospital resilience during external operations.Outside of the scope of the French Military Health Care Service, the present article provides insights into hospital resilience and financing systems for extra-care activities in hospitals such as teaching, research and public interest missions.; Les hôpitaux militaires français ont fait l’objet d’un rapport de la Cour des comptes établissant un déficit budgétaire important. Ce rapport soulève la question de la juste prise en compte des activités de défense dans le bilan financier de ces hôpitaux. Dans cet article, nous proposons d’étudier l’impact de la participation des personnels hospitaliers aux opérations extérieures sur le bloc opératoire afin de comprendre les implications des missions de défense pour l’organisation en terme d’activité de soin et donc de recettes.Notre étude repose sur une étude qualitative de ces questions, basée sur l’analyse de 27 entretiens menés au près de personnels hospitaliers, ainsi que sur une étude quantitative basée sur une simulation du processus chirurgical dans deux des neuf hôpitaux militaires.Les résultats de l’étude quantitative et qualitative convergent pour établir que la participation des personnels hospitaliers aux opérations extérieures peut induire une réduction variable de l’activité chirurgicale. Notre étude permet également d’établir que certaines stratégies organisationnelles mises en place par les personnels peuvent favoriser la résilience de l’hôpital sollicité pour les opérations extérieures.Au-delà du cadre des hôpitaux militaires, notre étude présente un intérêt méthodologique pour améliorer le financement des activités hors-soins (enseignement, recherche et missions d’intérêt général) et étudier la résilience à l’hôpital.

In view of the recent evolution of military conflicts, particularly in the Afghan theater, and the conditions in which wounded warriors are managed in the field prior to hospitalization, the authors examine the technical specificities of medical teams, based on studies of avoidable mortality. War surgery has become a separate specialty, following the disappearance in France of the general surgical specialty, of which it was the military coun-terpart. The authors stress the role of hemorrhaging and its treatment, based on three strategies: damage control resuscitation, blood transfusion, and early evacuation within the "golden hour ". The French Armed Forces Health Service, in a new strategic plan, is refocusing its activity on war traumatology, through better education and training of medical-surgical teams and by opening up its scholarship structures to the French civilian public health service sector.

Background From its origins, anaesthesia is a leading medical specialty for improving patient safety. However, perioperative adverse events remain frequent and may be preventable in 50% of cases. We conducted a collaborative retrospective study analysis of the insurance-database of the MACSF-Sou Medical insurance company to assess the perioperative risk. Material and methods Retrospective study, including all the statements declared by anaesthesiologists to the MACSF-Sou Medical insurance company. A description of risk in perioperative medicine was performed by the assessment of these statements by three experts member of the SFAR. All the statements concerning regional anaesthesia and dental injuries were excluded. Results Eight hundred and seventy statements were analyzed. The patients involved were predominantly women (sex-ratio: 0.86), with a mean age of 56 years (±18). Three hundred and fifteen cardiac arrests, 157 severe systemic complications, 340 moderate complications and 106 conflicts were analyzed. Most of the events were revealed postoperatively (79.3%) and almost half of them after the discharge of the postanesthetic care unit. The medical consequences were considered as serious. Death followed 35.9% of the events declared. Relative or true hypovolaemia and stroke were responsible for a large part of postoperative mortality and morbidity. Conclusion Collaborating with insurance companies allows a relevant approach of the perioperative risk. The study highlighted the importance of the delayed complications and is a plea for a more intense implication of anaesthesia in the postoperative care with the aim of improving patient safety.

Violations are deliberate deviations from standard procedure. The usual reaction is to attempt to eliminate them and reprimand those concerned. However, the situation is not that simple. Firstly, violations paradoxically may be markers of high levels of safety because they need constraints and defences to exist. They may even become more frequent than errors in ultrasafe systems. Secondly, violations have both positive and negative aspects. On the one hand they occur frequently, increase system performance and individual satisfaction, are mostly limited to practices with limited safety consequences, and therefore are often tolerated or even encouraged by the hierarchy. On the other hand, extreme violations can lead to real danger or actual harm. This paper proposes a three phase model derived from Rasmussen’s theory of migration to boundaries to explain the mechanism by which the deviance occurs, stabilizes, regresses, or progresses to harm. The model suggests that violations are unavoidable because system dynamics and deviances are markers of adaptation to this dynamicity. Violations cannot be eliminated but they can be managed. Solutions are specific to each step of the model, with a mix of relaxing constraints, increasing peer control (staff), and constraining dangerous individuals.

A National Confidential Inquiry was conducted among death certificators and anaesthetists. A sample of 3700 death certificates from the year 1999 were randomised, after selection of words relating to anaesthesia, surgery, obstetrics, endoscopy, procedural complications, and violent death, with different ratios according to the words and the age; 500 additional certificates relating to deaths in hospital were evaluated to verify the exhaustive nature of the mention of procedures in the certificates. The certificator was sent a simplified form each time the role of the procedure in death could not be excluded (response rate 97%). The anaesthetist was offered a peer review whenever the role of the anaesthetic procedure could not be ruled out (uptake rate 97%). An expert committee analysed the (anonymized) files to determinate the mechanism of the accident and its relationship to anaesthesia. The mortality rates were estimated from the 1996 "Anaesthesia in France" survey. The annual rates of deaths that were totally or partially related to anaesthesia were respectively 7 (CI95%: 2-12) and 47 (31-63) per million. These mortality rates increased with comorbidity, from 4 per million in patients of ASA physical status class 1 to 554 per million in class 4. Similarly, these rates increased with age, from 7 per million in patients less than 45 years old, to 32 in older patients. Most accidents were of ventilatory (38%: airway management: 6%, aspiration pneumonitis: 9%), cardiac (31%: ischaemia: 25%, including anaemia-related), and vascular origin (30%: hemorrhage: 12%, vasodilation by spinal anaesthesia: 6%, anaphylaxis: 3%). The main surgical procedures involved were orthopaedic (50%: hip fracture, haemorrhagic surgery) and digestive (24%: occlusion, peritonitis). INSERM had previously collected data on complications associated with anaesthesia between 1978 and 1982: the annual rates of deaths that were totally or partially related to anaesthesia were respectively 76 and 263 per million. Compared to these previous data, the anaesthesia-related mortality rate fell ten-fold over the last two decades, while the number of anaesthetic procedures at least doubled. In addition, the number of procedures involving old people and patients with poor physical status was multiplied by four. It seems logical to attribute these results to safety and practice guidelines published after the previous inquiry. Progress remains to be made: the present rate of 1/145000 will serve as a basis for systematic analysis of accidents.

Resume Objectifs. – Evaluer les benefices apportes par le recueil systematique des evenements peranesthesiques, par l'etude des facteurs associes a la declaration d'une hypotension arterielle peroperatoire. Type d'etude. – Etude retrospective avec analyses univariee et multivariee des facteurs associes a l'hypotension arterielle dans une base de donnees commune a deux hopitaux. Patients et methodes. – Un formulaire de recueil de l'activite, des techniques et des incidents anesthesiques a ete rempli manuellement pour chaque patient opere, puis traite dans une base de donnees. L'analyse porte sur les donnees de l'ensemble de l'annee 2001, limitee aux patients operes sous anesthesie generale de chirurgie orthopedique ou viscerale. Resultats. – Deux mille six cent quatre-vingt-onze anesthesies ont ete analysees. L'incidence de l'hypotension arterielle peroperatoire etait de 16,8 %. Les facteurs associes etaient : la duree de la chirurgie, l'âge et la classe ASA des patients. L'utilisation d'etomidate a l'induction n'apparaissait pas comme un facteur independant de modification du risque d'hypotension. Conclusion. – Les facteurs retrouves associes a l'hypotension etant independants des pratiques anesthesiques, les resultats ne permettent pas de faire evoluer celles-ci. Ceci conduit a poser la question de la pertinence des valeurs recueillies dans de telles bases de donnees.

Resume Objectif. – Determiner au niveau d’un pays les facteurs associes a la cœlioscopie en chirurgie digestive. Type d’etude. – Enquete nationale sur un echantillon representatif (trois jours d’anesthesie). Methodes. – Analyses univariees et multivariees des donnees recueillies par l’enquete de la Sfar de 1996, relatives a 2847 anesthesies pour cholecystectomie, appendicectomie, ou cure de hernie inguinale. Resultats. – Les facteurs independants associes a l’utilisation de la cœlioscopie etaient : dans les cholecystectomies : l’âge (moins frequente au-dela de 71 ans : AOR 0,4), le sexe (plus frequente chez la femme : AOR 1,7), une classe ASA ≥ 3 (AOR 0,5), un etablissement prive (AOR 2,0), une programmation avant la veille au soir (AOR 4,8) et l’utilisation d’un « circuit ferme » pour l’anesthesie (AOR 1,6) ; dans les appendicectomies : un âge > 15 ans (frequence doublee), le sexe feminin (AOR 2,1), un etablissement prive (AOR 2,7), la programmation (AOR 2,1), une duree d’intervention prolongee (AOR 8,4), l’intubation tracheale (AOR 16,7) et le « circuit ferme » (AOR 2,7) ; dans les cures de hernie inguinale : une classe ASA ≥ 3 (AOR 0,4), un etablissement prive (AOR 3,4), une duree prolongee (AOR 5,6) et l’intubation tracheale (AOR 21,6). L’association avec le « circuit ferme » a ete confirmee pour les anesthesies generales ayant comporte un agent volatil (AOR 1,5). Pour les trois interventions, la pratique ambulatoire etait exceptionnelle et ne concernait que les laparotomies. Les anesthesies locoregionales ne s’observaient pratiquement que dans les cures de hernie inguinale et ne concernaient egalement que les laparotomies. Conclusion. – L’etude a confirme, en la quantifiant au niveau national, la frequence plus elevee de la cœliochirurgie chez les patients d’âge moyen, de sexe feminin (sauf pour les cures de hernie inguinale), sans comorbidite importante, operes dans des etablissements prives. Pour les appendicectomies et les cures de hernie inguinale, la cœlioscopie etait associee a un allongement de la duree d’intervention et a un changement de technique anesthesique, avec intubation tracheale pratiquement systematique. Dans toutes les interventions, elle etait associee au « circuit ferme », reflet d’un equipement anesthesique plus recent, independamment du statut public ou prive de l’etablissement.

Summary Background: There are no epidemiological data describing tracheal intubation and laryngeal mask airway (LMATM) use in paediatric anaesthesia. This analysis focused on the factors leading to the indication for an airway management procedure, i.e. tracheal intubation and laryngeal mask airway vs face mask during general anaesthesia for tonsillectomy and appendicectomy. Methods: The data were recorded in the French survey of Practical Anaesthesia performed in 1996. Two main types of surgical procedures were selected: tonsillectomy and appendicectomy because of the number of patients and the need to use an invasive airway management technique. Results: During a 1-year period, 627 anaesthetics for appendicectomy and 653 anaesthetics for tonsillectomy were recorded in the sample under consideration. Tracheal intubation or laryngeal mask airway was undertaken in 66% of tonsillectomies and 84% of appendicectomies. Univariate analysis showed that tracheal intubation/laryngeal mask were used significantly more often in older children, with long duration of anaesthesia, in nonambulatory procedures and in procedures performed at an academic centre. When these variables were included in a multivariate analysis, the duration of anaesthesia over 30 min was a factor linked to the use of tracheal intubation/laryngeal mask airway for the two types of surgery (P

Resume Objectif : Determiner au niveau d’un pays les facteurs explicatifs de la transfusion peroperatoire de sang homologue et du choix d’une technique autologue (transfusion autologue programmee : TAP ; hemodilution normovolemique intentionnelle : HDNI ; recuperation peroperatoire : RPO). Type d’etude : Enquete nationale sur un echantillon representatif (3 jours d’anesthesie). Methodes : Analyses univariees et multivariees des donnees recueillies par l’enquete de la Sfar de 1996, relatives a 884 anesthesies pour prothese totale de hanche ou de genou programmees. Resultats : Les facteurs associes a une technique autologue ont ete : un moindre recours a la TAP chez les personnes les plus âgees et les plus atteintes d’une comorbidite ; un moindre recours a la TAP pour les interventions les plus courtes ; un recours plus frequent a la TAP lorsquˈun circuit ferme etait utilise ; en dehors de lˈâge et de lˈabsence de TAP, il nˈa pas ete note de facteur explicatif pour lˈHDNI ; aucun facteur nˈa ete trouve pour la RPO. Les facteurs associes a la transfusion peroperatoire de sang homologue ont ete : une plus grande frequence chez les personnes de classe ASA ≥ 3 ; une plus grande frequence dans les anesthesies de longue duree ; une reduction par un facteur de 4,4 〚intervalle de confiance a 95 % : 2,2-8,8〛 en cas dˈutilisation de la TAP ; aucun lien nˈa ete retrouve avec lˈHDNI ou la RPO. Conclusion : Ces donnees ont confirme au niveau de la France les resultats des meta-analyses des etudes controlees concernant la TAP et l’HDNI et peuvent s’expliquer par les recommandations actuelles. Elles ont mis en evidence un lien inattendu entre le type de circuit anesthesique utilise et la TAP.

Epidural analgesia is the most efficient technique for labor pain relief. However, its resultant motor block might impair the mode of delivery, particularly in breech presentation where the risk of dystocia is high. In this trial, we compared bupivacaine 0.125% with a combination of a low concentration of bupivacaine (0.0625%) and sufentanil (0.25 μg·mL −1 ) both administered by continuous infusion. Analgesia, maternal and fetal/neonatal side effects and obstetric outcome were compared between group bupivacaine ( n =23) and group bupivacaine-sufentanil ( n =35). A greater number of patients in the bupivacaine 0.125% group required more than two top-ups (32 vs. 8% of patients, P =0.03) while pain scores were similar. Motor block at delivery was more pronounced in the bupivacaine 0.125% group. Nausea and pruritus were more often encountered in the bupivacaine-sufentanil group. There was a trend toward a decreased rate of assisted or operative delivery in the bupivacaine-sufentanil group (92% vs. 74%, P =0.09). Fetal/neonatal data did not differ between groups. Epidural analgesia with bupivacaine-sufentanil required fewer additional top-ups and produced less motor block than did bupivacaine 0.125%. However, there was no significant difference in mode of delivery between the two analgesic regimens.

In hospitals, availability of human resources is highly variable: absences and non patient-care activities impact considerably the organisation of the hospital. Making cost-effective staffing decisions is thus complex and can be of high importance in a costly and highly technical area such as the operating suite. Our research question is: 'what is the impact of non patient-care activities on the surgical activity of the hospital?'A deterministic simulation of the surgery production process is developed based on 43 semi-directive interviews conducted in five French military hospitals. We apply our simulation to a case study based on the participation of military nurses and practitioners in temporary military missions abroad for two military hospitals. Two main findings arise from our study. First, medical staff has high flexibility in work organisation that favours balancing the impact of colleagues' absence. Second, respecting the equilibrium of staffing levels in the hospital appears crucial to limit the impact of non patient-care missions on the efficiency of hospitals.

Introduction The use of a stethoscope is essential to the delivery of continuous, supportive en route care during aeromedical evacuations. We compared the capability of 2 stethoscopes (electronic, Litmann 3000; conventional, Litmann Cardiology III) at detecting pathologic heart and lung sounds, aboard a C135, a medical transport aircraft. Methods Sounds were mimicked using a mannequin-based simulator SimMan. Five practitioners examined the mannequin during a fly, with a variety of abnormalities as follows: crackles, wheezing, right and left lung silence, as well as systolic, diastolic, and Austin-Flint murmur. The comparison for diagnosis assessed (correct or wrong) between using the electronic and conventional stethoscopes were performed as a McNemar test. Results A total of 70 evaluations were performed. For cardiac sounds, diagnosis was right in 0/15 and 4/15 auscultations, respectively, with conventional and electronic stethoscopes (McNemar test, P = 0.13). For lung sounds, right diagnosis was found with conventional stethoscope in 10/20 auscultations versus 18/20 with electronic stethoscope (P = 0.013). Conclusions Flight practitioners involved in aeromedical evacuation on C135 plane are more able to practice lung auscultation on a mannequin with this amplified stethoscope than with the traditional one. No benefit was found for heart sounds.

Introduction Le dossier d’anesthesie contribue au partage de l’information entre les differents acteurs intervenant a chaque etape de la prise en charge anesthesique. Depuis 2008, la HAS coordonne un dispositif de generalisation d’indicateurs de qualite et a realise la 5e campagne nationale de recueil de l’indicateur « Tenue du dossier anesthesique » en MCO. Les resultats nationaux des annees precedentes et les resultats des differents etablissements sont diffuses sur Scope sante ( www.scopesante.fr ). Materiel et methodes Pour chaque etablissement, 60 dossiers tires au sort ont ete examines, en excluant les dossiers des enfants de moins de 10 ans. L’indicateur est presente sous la forme d’un score de qualite calcule a partir de 13 criteres. La qualite de la tenue du dossier patient est d’autant plus grande que le score est proche de 100. Un objectif national de performance de 80 % a ete fixe initialement par la HAS. Resultats La campagne de 2014 a concerne des dossiers du second semestre de 2013 ou 98 % des etablissements (897) ayant une activite d’AG ou ALR et presentant donc une obligation de recueil ont participe. Parmi les dossiers anesthesiques, 58 947 ont ete analyses, representant des patients d’âge moyen 51 ans, de classe ASA1 ou 2 pour 83 % et 58 % de femmes. Le taux d’informatisation de la consultation d’anesthesie etait de 59 %. Ce 5e recueil national montre que la tenue du dossier anesthesique s’est amelioree en 5 ans (+ 19 points) : le score moyen national brut est passe de 67 % (2008) a 86 % (2014). En 2014, 85,4 % des etablissements de sante ont atteint ou depasse l’objectif de performance de 80 %, mais la variabilite nationale persiste (48 %–100 %). Deux cent soixante-quatorze etablissements (29,3 %) ont augmente significativement leur score entre les deux campagnes et 143 (15,3 %) ont regresse en termes de performance par rapport aux donnees anterieures. Discussion La plupart des criteres integres dans le score composite TDA presentent des taux de conformite eleves ( Fig. 1 ), cependant plusieurs d’entre eux peuvent encore etre ameliores. Par exemple, l’identification du medecin anesthesiste sur le document tracant la phase preanesthesique (consultation et/ou visite) est retrouvee dans 76 % des dossiers, ainsi que la tracabilite des incidents peri-anesthesiques (67 %). On retrouve seulement 64 % des dossiers analyses avec une trace ecrite des prescriptions medicamenteuses destinees aux unites d’hospitalisation. Dans 84 % des dossiers, la mention de l’evaluation des conditions d’abord des voies aeriennes superieures est notee et comporte le score de Mallampati (92 %), la distance thyro-mentonniere (74 %), l’ouverture de bouche (82 %), ou un commentaire precisant s’il y a ou non des difficultes previsibles d’intubation (70 %). La gravite potentielle du risque exigerait une qualite parfaite avec un critere a 100 % mais le suivi des 5 annees d’audit montre une amelioration progressive et importante puisque le taux enregistre lors de la premiere campagne (2007) etait de 47 %. En 2014, deux nouveaux indicateurs concernant la prise en charge de la douleur ont ete recueillis par l’ensemble des etablissements. Apres validation par les professionnels, ils feront l’objet d’une diffusion publique lors de la prochaine campagne.