**6. General discussion**

The main objective pursued in this article was to emphasize the risk assessment during the consultation (phase 1 of the process) and during the anaesthesia (phase 2). More specifically, 2 questions have structured our work: (1) what kind of risk is used when anaesthetist has to assess a patient's file? (2) How important are the risk frequency and the risk predictability in the assessment and the management in real time?

The first research permits us to answer the first question and to study the effect of the experience level on the risk assessment. Our analyses show that the most experimented anaesthetists differentiate more patients' files regarding to the number of categories formed, the labels given and their verbalizations. Concerning the kinds of risks used, the experimented anaesthetists use most often the complexity linked to the patient to assess a file whereas novices use a more general level of risk without distinction between patient,

Fig. 6. Percentage of correct recovery actions according to the predicatbility and the

In the following section, all the results will be explained regarding the theories used.

The main objective pursued in this article was to emphasize the risk assessment during the consultation (phase 1 of the process) and during the anaesthesia (phase 2). More specifically, 2 questions have structured our work: (1) what kind of risk is used when anaesthetist has to assess a patient's file? (2) How important are the risk frequency and the risk predictability in

The first research permits us to answer the first question and to study the effect of the experience level on the risk assessment. Our analyses show that the most experimented anaesthetists differentiate more patients' files regarding to the number of categories formed, the labels given and their verbalizations. Concerning the kinds of risks used, the experimented anaesthetists use most often the complexity linked to the patient to assess a file whereas novices use a more general level of risk without distinction between patient,

In this second study, we wanted to see how anaesthetists assessed risks before and during the surgery. We were interested by two kinds of variables: the predictability and the occurrence frequency. Our results showed that anaesthetists assessed problems as more risky when they can anticipate it than when they are unforeseeable. However, few anaesthetists were able to correctly assess the risks during the consultation. In fact, their representation were often distorted by others problems. It means that they put a lot of warning flags for each case. One variable seem relevant in the risk assessment and management: the frequency. A frequent risk is always correctly identified and recovered.

frequency

**5.3 Brief discussion of the second study** 

the assessment and the management in real time?

**6. General discussion** 

surgery and anaesthesia risk, even if their verbalizations show that they use the patient and the surgery criteria with almost the same frequency. Both of them use more information according to the files complexity. Finally, the two groups of anaesthetists use some warning flags to underline some specific problems.

Through this study, our results show that the more experimented anaesthetists build more functional representations because they analyse the situation more broadly. This confirms the results of Cellier et al. (1997) and Hoc (1989). In other words, experimented anaesthetists consider two levels of risk (the patient and the surgery) even if they use more often the criteria related to the patient. That should enable them to anticipate potential incidents associated with the patient and the surgery.

Our results also confirm that two variables can influence the consultation (Anceaux et al., 2001, 2002, 2005): the level of experience and the case complexity. Finally, regarding information used by anaesthetists (all experience level combined) to assess a file, they all point out specific problems. This last point confirms Xiao's results (et al., 1997).

All these elements show that the risk assessment during the consultation leads to a schematic representation that can be then specified later during the surgery (Hoc, 1987).

The second research permits to answer the second question (How important are the risk frequency and the risk predictability in the assessment and the management in real time?). Our results indicate that the risk predictability increases the perceived difficulty level associated with it. Moreover this perceived difficulty is higher when the risk is both frequent and predictable. The risk frequency seems to be important for the identification during the surgery and also for the recovery actions.

Overall, few anaesthetists assess the problem correctly at the end of the consultation (for recall: only 35.9% of anaesthetists assess the real risk). Anaesthetists correctly assess only frequent and predictable risks at this early stage. Concerning the other risks, the anaesthetist's representation is distorted by other problems. Even if the risk is not really perceived during the consultation, the identification is almost correct for all the anaesthetists. We also find that anaesthetists identified and recovered less correctly the infrequent risks.

Finally our results point out that anaesthetists suggest that anaesthetists propose several hypotheses before reaching the right result whatever the nature of the risk according to its frequency and its predictability.

These results confirm epidemiological and psychological studies previously cited. In fact, several explanations can be given to our results. Firstly, previsability permits to assess (consultation) and to identify (surgery) correctly the risks. Secondly, as Cooper's results (et al., 1982) showed, anaesthetists not taken into account infrequent risks. These ones are not correctly assessed, identified and recovered because there is a misunderstanding. Indeed the majority of anaesthetists faced with a infrequent risk explained that they have been rarely confronted with this kind of risk and most often through simulations. Thus, when the patient presented signs of this problem, they tended to minimize the facts (Amalberti, et al., 2005). Moreover, their representation seems distorted by highlighting other problems (points for consideration, Xiao, et al., 1997). Finally, frequent and predictable risks are most

Risk Assessment in the Anaesthesia Process 225

This chapter, in line with the work on resilience, contributes to a positive view of risk management in anaesthesia. The operator is a central key to the system resilience, not only in terms of preparation but also in real-time management. It points out adaptation strategies to the system variabilities by a proactive identification of risk factors and reactive strategies in

Finally, the use of different approaches to address resilience is relevant, it permits to obtain and confront additional information. It is interesting to use several techniques to obtain additional information. However, methods used are subject to numerous biases. The categorization of files can not really be considered as a consultation. The patient was not present, the anesthetist has to build his representation on written data, not physical or verbal ones. In the simulation, the anesthetist is confronted alone to the case but it is a team-work where detection by a third person is very important. Thus, detection strategies could not be identified. Moreover, in this second study, we focused on the risks occurring in the operating room. It is clear that these risks also require increased monitoring after surgery because they can affect the patient's health. However, for purposes of the study, the simulation did not take

This research project would not have been possible without the support of many people. The lead author wishes to express her gratitude to her three colleagues, Prof. Dr. Cellier, Dr. Carreras and Ms Planes who offered invaluable assistance, support and guidance in these two studies. She also whishes to thank all the anaesthetists who were abundantly helpful to understand their work. Deepest gratitude are also due to all the members of the Laboratory of Cognition for sharing the literature and invaluable assisstance, and the members of the French Society of Anaesthetists whithout whose knwoledge and assistance these studies would not have been successful. The authour would also like to convey the Faculty for

Finally, the lead author would also like to express her love and gratitude to her beloved

Allwood, C.M., & Montgomery, P. (1982). Detection of errors in statistical problem solving.

Allwood, C.M. (1984). Error detection processes in statistical problem solving. *Cognitive* 

Amalberti R, Auroy Y, Berwick D, Barach P. (2005). Five system barriers to achieving

Anceaux, F., & Beuscart-Zéphir, M.C. (2002). La consultation préopératoire en anesthésie :

Anceaux, F., Thuilliez, H., & Beuscart-Zéphir, M.C. (2001). Gestion de la prise

gestion de la prise d'informations et rôle des données retenues dans la planification

d'informations pour la planification en situation dynamique : l'anesthésie. In V.

response to changes of the patient's health conditions (Patterson et al., 2010).

into account the latter period.

providing the financial means and laboratory facilities.

*Scandinavian Journal of Psychology*, *23*, 131-139.

ultrasafe health care. *Ann Intern Med, 142*(9), 756-764.

du processus d'anesthésie. *Le Travail Humain*, *65*(1), 59-88.

families for their understanding and endless love.

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**8. Acknowledgment** 

**9. References** 

often correctly assessed, dectected and recovered. The explanation lies in algorithms developed and the current practice that allow the anaesthetist to identify problems quickly (by information filtering).
