Skip to main content
SpringerLink
Log in

Modalités de prévention et de retour sur l’erreur dans deux univers clos et sous pression

Analysis and prevention of errors in closed and under-pressure systems

  • Article Original / Original Article
  • Published:
Réanimation

Résumé

Un service de réanimation et un bâtiment de combat de la Marine nationale présentent quelques similitudes: rapport à la mort, service continu, fatigue, stress et univers très technicisé. Ces similitudes incitent à comparer les modalités de prévention et de retour sur l’erreur, pour identifier les problèmes communs et échanger des idées d’amélioration. Malgré des modalités manifestement différentes, le problème central de la culpabilisation est un frein commun à l’établissement d’un système de progrès fondé sur l’analyse des dysfonctionnements.

Abstract

An intensive care unit and a warship share some similarities: proximity to death, operating 24/7, fatigue, tension, and preeminence of high-technology. These similarities encourage to compare methods to prevent and analyse errors in both systems. A comparison was intended to identify common problems and exchange ideas for improvement. Despite clearly different systems, the central problem of guilt is a common obstacle to the establishment of a system of progress based on the analysis of malfunctions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Références

  1. Rasmussen J, Jensen A (1974) Mental procedures in real-life tasks: a case study of electronic trouble shooting. Ergonomics 17:293–307

    Article  PubMed  CAS  Google Scholar 

  2. Garrouste-Orgeas M, Timsit JF, Vesin A, et al (2010) Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. Am J Respir Crit Care Med 181:134–142

    Article  PubMed  Google Scholar 

  3. Garrouste Orgeas M, Timsit JF, Soufir L, et al (2008) Impact of adverse events on outcomes in intensive care unit patients. Crit Care Med 36:2041–2047

    Article  PubMed  Google Scholar 

  4. Pottier V, Daubin C, Lerolle N, et al (2011) Overview of adverse events related to invasive procedures in the intensive care unit. Am J Infect Control

  5. Schouten JA, Hulscher ME, Kullberg BJ, et al (2005) Understanding variation in quality of antibiotic use for community-acquired pneumonia: effect of patient, professional and hospital factors. J Antimicrob Chemother 56:575–82

    Article  PubMed  CAS  Google Scholar 

  6. http://www.securitesoins.fr/evenements-indesirables-lies-auxsoins/05_fr_05_05.html

  7. Yerly P, Vachiéry J (2011) Anorexigènes et maladies cardiovasculaires: les liaisons dangereuses. Reanimation 20:424–435

    Article  Google Scholar 

  8. Olt F, Wilson D, Ron A, et al (1997) Quality improvement through review of inpatient deaths. J Healthc Qual 19:12–18, 44

    Article  PubMed  CAS  Google Scholar 

  9. Amalberti R, Pibarot M (2003) La sécurité du patient revisitée avec un regard systémique. Gest Hosp 422:18–25

    Google Scholar 

  10. Westrum R (2004) A typology of organisational cultures. Qual Saf Health Care 13Suppl 2:ii22–7

    Article  PubMed  Google Scholar 

  11. Haute Autorité de santé RMM Guide méthodologique. http://www.has-sante.fr/portail/upload/docs/application/pdf/2009-08/guide_rmm_juin_09.pdf

  12. Ksouri H, Balanant PY, Tadie JM, et al (2010) Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice. Am J Crit Care 19:135–145; quiz 146

    Article  PubMed  Google Scholar 

  13. http://www.oedipe.org/fr/actualites/lademarchequalite

Download references

Author information

Authors and Affiliations

  1. Département de réanimation médicale et de médecine hyperbare, CHU d’Angers, F-49933, Angers, France

    N. Lerolle & J. de Saint-Quentin

Authors
  1. N. Lerolle
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. de Saint-Quentin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N. Lerolle.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lerolle, N., de Saint-Quentin, J. Modalités de prévention et de retour sur l’erreur dans deux univers clos et sous pression. Réanimation 21, 648–656 (2012). https://doi.org/10.1007/s13546-012-0473-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13546-012-0473-x

Mots clés

Keywords

Search

Navigation