Unforeseen Events in Paediatric Anaesthesiology

摘要

Anaesthesia consists in inducing a reversible lack of awareness, in order to allow patients to undergo surgery without distress and pain. In the field of patient safety, this medical discipline is viewed as a pioneer and is considered as an ultra-safe system. In this context, our empirical research conducted in a paediatric anaesthesiology service within a French hospital aims to identify and characterize the residual risks and the uncertainties that confront the practitioners in their everyday work, in order to continu to progress on patient safety. Methods employed were based on work observations and on a posteriori interviews with trained anaesthetists. Results show that there are different types of 'unforeseen events” ant that uncertainty relates to the medical, organizational and technical dimensions of working situations. It is argued that a new approche is needed to continue to progress on safety, and that it is necessary to develop the system's ability to cope with unthought events rather than trying to anticipate and eliminate all adverse events. It is suggested that the study of “flexibility point” could be a way for developping this new approach.