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Analyse des causes- racines: une dynamique d ployer

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Analyse des causes- racines: une dynamique d ployer

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    1. Analyse des causes- racines: une dynamique dployer Pr Dan BENHAMOU Dpartement dAnesthsie-Ranimation Hpital Bictre, Universit Paris-Sud Commission nationale dhmovigilance

    3. La prise en charge du patient: Un risque important de complications inattendues

    4. ENEIS 2005, mmes rsultats en France

    5. Les erreurs dans les activits humaines Plus de 90 % des accidents sont lis des erreurs humaines Involontaires De routine (70 80 %) Erreurs de reconnaissance Rgles (mauvaise slection, 15 20%) Modles de connaissances (manque de) (moins de 5% ) Frquentes: 2 10 par heure Auto-rcupration trs leve: moyenne 70 80%, dont 90% pour les seules erreurs de routine dtection sur rsultat bizarre, sur traces ou contrle systmatique Volontaires = Violations (aussi frquentes que toutes les erreurs involontaires)

    7. Facteurs favorisants des carts

    8. Le risque en fonction de lactivit

    11. Erreurs et consquences de lerreur Le risque nest pas li lerreur, il est li au contexte de situation As you can see on this picture, the consequences of an error may be very different from one situation to another. However, it is still the same error. Therefore, we must clearly differentiate between an error and its consequences. The best example of the difference between an error and its consequences can be found in your own training. Why do we have simulators? So that pilots can learn from their errors, without suffering the consequences of that error as they would in the air. Consider the difference between an error made in the simulator and the exact same error made in the air. Another alternative example of consequence: imagine now that our old lady lives in Venice this time the flower pot will fall into water. There wont be any visible consequences, except the loss of the flower pot!As you can see on this picture, the consequences of an error may be very different from one situation to another. However, it is still the same error. Therefore, we must clearly differentiate between an error and its consequences. The best example of the difference between an error and its consequences can be found in your own training. Why do we have simulators? So that pilots can learn from their errors, without suffering the consequences of that error as they would in the air. Consider the difference between an error made in the simulator and the exact same error made in the air. Another alternative example of consequence: imagine now that our old lady lives in Venice this time the flower pot will fall into water. There wont be any visible consequences, except the loss of the flower pot!

    12. Identification des risques Observations directes Revues de dossiers Revues de direction Systme de signalement Classe 1: dclarations par les professionnels EIG vs EPR Classe 2: dclarations par les patients Classe 3: bass sur les traces

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