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Publications (10)8.76 Total impact

  • J-V Schaal, G De Saint Maurice, B Clavier, S Ausset, B Lenoir
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    ABSTRACT: We report the perioperative management of a woman expressing an antibody against high frequency red cell antigen (anti-Kel4 antibody anti-kpb) who was scheduled for a total knee replacement. A specific strategy was designed to afford this major orthopedic surgery, considering specially the occurrence of unusual bleeding higher than the average bleeding assessed in our hospital in this indication. The transfusion of incompatible red cells may be responsible for acute hemolytic reaction. An autologous transfusion program, including cryopreservation, erythropoietin and iron support, was provided. Three autologous red cells units were collected before surgery. Compatible homologous red cells units were also available at the French bank for rare blood groups. We report logistical and medical problems that have occurred during the perioperative period.
    Annales francaises d'anesthesie et de reanimation 03/2011; 30(5):436-9. · 0.77 Impact Factor
  • Annales francaises d'anesthesie et de reanimation 02/2011; 30(4):329-30. · 0.77 Impact Factor
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    ABSTRACT: The mistake-proofing concept often refers to physical devices that prevent actors from making a wrong action. In anaesthesiology, one immediately thinks to specific design of outlets for medical gases. More generally, the principle of mistake-proofing is to avoid an error, by placing knowledge in the world rather than knowledge in the head. As it often happens in risk management, healthcare has received information transfers from the industry. Computer is changing the concept of mistake-proofing, initially based on physical design, such as aerospace and automotive industry. The mistake-proofing concept may be applied to prevention, detection, and mitigation of errors. The forcing functions are a specific part of mistake-proofing: they prevent a wrong action or they force a virtuous one. Grout proposes a little shortcut to identify mistake-proofing devices: “If it is not possible to picture it in action, it is probably not a mistake-proofing device”.
    Annales Francaises D Anesthesie Et De Reanimation - ANN FR ANESTH REANIM. 01/2011; 30(1):51-56.
  • J.-V. Schaal, G. De Saint Maurice, B. Clavier, S. Ausset, B. Lenoir
    [Show abstract] [Hide abstract]
    ABSTRACT: We report the perioperative management of a woman expressing an antibody against high frequency red cell antigen (anti-Kel4 antibody anti-kpb) who was scheduled for a total knee replacement. A specific strategy was designed to afford this major orthopedic surgery, considering specially the occurrence of unusual bleeding higher than the average bleeding assessed in our hospital in this indication. The transfusion of incompatible red cells may be responsible for acute hemolytic reaction. An autologous transfusion program, including cryopreservation, erythropoietin and iron support, was provided. Three autologous red cells units were collected before surgery. Compatible homologous red cells units were also available at the French bank for rare blood groups. We report logistical and medical problems that have occurred during the perioperative period.
    Annales Francaises D Anesthesie Et De Reanimation - ANN FR ANESTH REANIM. 01/2011; 30(5):436-439.
  • G de Saint Maurice, N Giraud, S Ausset, Y Auroy, B Lenoir, R Amalberti
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    ABSTRACT: The mistake-proofing concept often refers to physical devices that prevent actors from making a wrong action. In anaesthesiology, one immediately thinks to specific design of outlets for medical gases. More generally, the principle of mistake-proofing is to avoid an error, by placing knowledge in the world rather than knowledge in the head. As it often happens in risk management, healthcare has received information transfers from the industry. Computer is changing the concept of mistake-proofing, initially based on physical design, such as aerospace and automotive industry. The mistake-proofing concept may be applied to prevention, detection, and mitigation of errors. The forcing functions are a specific part of mistake-proofing: they prevent a wrong action or they force a virtuous one. Grout proposes a little shortcut to identify mistake-proofing devices: "If it is not possible to picture it in action, it is probably not a mistake-proofing device".
    Annales francaises d'anesthesie et de reanimation 01/2011; 30(1):51-6. · 0.77 Impact Factor
  • Revue D Epidemiologie Et De Sante Publique - REV EPIDEMIOL SANTE PUBL. 01/2010; 58.
  • M Boutonnet, G De Saint Maurice, S Cottez Gacia, S Ausset
    Acta Anaesthesiologica Scandinavica 10/2009; 53(8):1100-1. · 2.36 Impact Factor
  • S Ausset, G Pelé De Saint Maurice, P Vest, A Cirodde, J-M Martin, Y Auroy
    Injury 01/2009; 40(1):111-2. · 1.93 Impact Factor
  • Source
    R Amalberti, C Vincent, Y Auroy, G de Saint Maurice
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    ABSTRACT: 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.
    Quality and Safety in Health Care 01/2007; 15 Suppl 1:i66-71. · 2.16 Impact Factor
  • European Journal of Anaesthesiology - EUR J ANAESTH. 01/2006; 23.