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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 ŕ déployer Pr Dan BENHAMOU Département d’Anesthésie-Réanimation Hôpital Bicętre, Université Paris-Sud Commission nationale d’hémovigilance

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

    4. ENEIS 2005, męmes résultats en France

    5. Les erreurs dans les activités humaines Plus de 90 % des accidents sont liés ŕ des erreurs humaines Involontaires De routine (70 ŕ 80 %) Erreurs de reconnaissance Rčgles (mauvaise sélection, 15 ŕ 20%) Modčles de connaissances (manque de) (moins de 5% ) Fréquentes: 2 ŕ 10 par heure Auto-récupération trčs élevée: moyenne 70 ŕ 80%, dont 90% pour les seules erreurs de routine détection sur résultat bizarre, sur traces ou contrôle systématique Volontaires = Violations (aussi fréquentes que toutes les erreurs involontaires)

    7. Facteurs favorisants des écarts

    8. Le risque en fonction de l’activité

    11. Erreurs et conséquences de l’erreur Le risque n’est pas lié ŕ l’erreur, il est lié 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 won’t 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 won’t be any visible consequences, except the loss of the flower pot!

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

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