**1. Introduction**

204 Novel Approaches and Their Applications in Risk Assessment

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Typically, the patient considers the anaesthesia process as risky (Marty, 2003). Indeed, the anaesthetist has to understand risks related to the patient and also to the surgery. There are many ways to define risks according to the point of view adopted.

In medical setting, risk can be defined using the ISO 12000-1 and the OSHAS 18001 standards. So, risk is defined as a measure of threat expressed in terms of the occurrence of an adverse event (*i.e.* its probability and its frequency) and a measure of its effects or its consequences. In anaesthesia, three criteria are commonly used to describe risk: the event gravity, the occurrence frequency and the level of acceptability. The first one, the event gravity, can be seen as a qualitative scale with 4 major steps: minor risk (*i.e.* error without prejudice for the patient), significant risk (*i.e.* self–limiting prejudice), major risk (*i.e.* error needing a recovery action) and risk evaluated as serious to critical (*i.e.* permanent damage). The second scale, the occurrence frequency, contains 5 major steps: highly unlikely (*i.e.*  frequency≤10-5), very unlikely (*i.e.* 10-5<frequency≤10-4), unlikely (*i.e.* 10-4<frequency≤10- 3), probable (*i.e.* 10-2<frequency≤10-1) and very likely to sure (*i.e.* >10%). The last one, the level of acceptability, is divided into 3 parts: non-critical risks (*i.e.* acceptable risky situations), risks to be monitored (*i.e.* acceptable risky situations but actions are needed to identify and monitor them) and rush through risks (*i.e.* not acceptable risky situations requiring actions to reduce risks or to monitor them).

In France, there is a step entirely devoted to anaesthesia risk assessment: the pre-anaesthesia consultation. But this is a French uniqueness. Indeed, in other countries (*e.g.* Quebec), the anaesthetist will see the patient at the entrance to the operating room. However, the anaesthetist may not assess all risks during the anaesthesia consultation. In this chapter, we will study how does an anaesthetist assess risks linked to a patient who must have a surgical operation before and during this one.

We will present this chapter as follow. First, we will describe the anaesthesia process in France and some epidemiological studies on risks in anaesthesia. Then, we will present some cognitive psychology concepts related to planning, information gathering, resilience engineering and management (*i.e.* error detection, identification and recovery). Two studies will be presented by the method used and results obtained. The first one concerns a card sorting experimentation (with patient records) to understand how anaesthetists gather

Risk Assessment in the Anaesthesia Process 207

This phase, the first box on the left, allows the anaesthetist to prepare the patient for the surgery and to highlight important elements to consider during this one (Anceaux & Beuscart-Zéphir, 2002). Due to the French specificity (for recall, the existence of a specific consultation). This first phase is divided into two different steps: the consultation and the

The consultation takes place 2 weeks before the surgery. During this one, the anaesthetist looks for information about the patient's disease through interviews (medical history, comorbidities, medication and allergies) and physical examination, establishes a family medical history and tries to reassure the patient. This one allows the anaesthetist to prescribe additional tests, to adapt the treatment, and if needed, to optimize the patient's

The second step, the anaesthetic visit, takes place the day before or the same day of the surgery. Its major aim is to verify the absence of interfering elements occurred between the

This second phase starts when the anaesthetist meets the patient at the entrance to the operating room. Two different steps compose this phase. The first one is the anaesthesia induction. It means the administration of anaesthetic agents and the establishment of adequate depth anaesthesia for surgery. It is an important step physically and mentally (McDonald & Dzwonczyk, 1988; McDonald et al*.*, 1990; Gaba & Lee, 1990). Physically because a lot of actions are needed (Xiao, 1994): preparation and injection of anaesthetic drugs, airway intubation, breathing circuit connections, programing a precise mechanical ventilation, etc. Mental workload is also observed. In fact, the patient's physiological status will change very quickly due to injected drugs. To interpret all the information relayed by the monitoring and the physical examination, the anaesthetist has to construct a specific

representation of the patient's health state. Then, he has to check the data progress.

the schedule or to check the drugs effect, or for a personal need.

The second step of this phase is the maintenance of anaesthesia throughout the medical procedure. During this step, the anaesthetist's main task is to monitor the patient's vital

A task analysis (Neyns, 2011) has highlighted 4 categories of anaesthetists' observable

The first category relates to the anaesthetist's need to monitor the situation, assess the evolution of specific variables, understand the situation, etc. It is the **information-gathering step**. Five sources were underlined: *the patient's record* that includes both the pre-anaesthetic file (form the consultation and additional assessments) and the per-operative sheet that includes all patient data (drugs injected, vital signs, all relevant information); the *monitoring and its alarms*; the *surgery status and progress* allowing to explain changes in patient's vital signs or to restore the patient's anaesthesia; information taking on *patient* (apart from monitoring data) used to confirm hypothesis; and information related to *hour* either to check

**2.1.1 The pre-operatory phase** 

anaesthetic visit.

consultation and the visit.

**2.1.2 The per-operatory phase** 

signs and the progress of surgery.

behaviours.

health.

patient's files according to their risk. While the second one consists in semi-structured interviews revolved on simulated cases using the information on request technique. Finally, our results will be discussed in regard of theories used.
