1 Safety And Resilience In Anesthesia

1.1 From safety to resilience

1Traditional safety approaches are focused on risks prevention: they rely on models that explain the origin of adverse events and the mechanisms of their occurrence from causal explanations Even if the shape of these models has changed (sequential, epidemiological or migrational models) and the risk factors have evolved (technical, human, organizational or economic factors), the origin of adverse events is always attributed to the presence of causes, more or less close to the “ultimate event”, that lead to the drift of the system toward an incidental chained scenario (Hollnagel, 2004, 2010; Sheridan, 2008). Thus, in all these traditional approaches, improving safety requires actions against these risk factors, aiming as far as possible to remove them. In practice, this means the establishment of different types of barriers (physical, functional, symbolic, etc.), the purpose of which is to avoid or control anticipated failures (Hollnagel, 2004). In these approaches, it is more or less explicitly accepted that these barriers enhance safety. In other words, if the system remains within the expected margins, there will be no accidents, as if the existence and application of formalisms developed to deal with anticipated failures could ensure the absence of risk.

2These traditional approaches have limitations that have been the subject of much criticism in recent decades. On the one hand, socio-technical systems have evolved a lot, making “obsolete” the tools previously used: in the complex and "ultra safe" systems of today, traditional measures no longer lead to progress in terms of safety and may even be counterproductive (Amalberti, 2001; Dien, 1998). On the other hand, traditional approaches have inherent limitations:

• They seek to reduce and constrain the variabilities of situations without taking into account the existence of a mandatory gap between prescribed work and real work. In doing, so, they ignore that safety is also based on the strategies, initiatives, tinkering and ingenuity brought by individual and collective skills in real time (Cook, Render, & Woods, 2000; Daniellou, Simard, & Boissières, 2009; Leplat, 1998).
• They are based on causal explanations focused on failures that do not understand how risks (and even less how safety) emerge from “normal conditions”. In this sense, they do not improve our knowledge of real situations but aim rather to establish reassuring certainties that ensure stakeholders that the threat revealed by the failures is now under control (Hollnagel, Pariès, Woods, & Wreathall, 2010; Woods & Cook, 2002).

3A radical revision of how we think about risks and safety is then needed. This is the goal of the “resilience engineering” approach. As a matter off fact, the concept of “resilience” is not yet stabilized (Sheridan, 2008). According to the latest definition proposed by Hollnagel, it means: " the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions” (2010, p. xxxvi). The many debates around this definition question the way we describe and understand the systems and the variable conditions under which they operate. In particular, they invite us to move our safety analysis from an approach focused on failures to a more general understanding of “safely acting”: the resilience’s studies aim not only to understand why a system is safe but also to identify what enables it to be effective and efficient in all conditions. Their goal is not so much to understand the causes of negative events, but to understand how operators at various levels in organizations adapt and act, so that the system can function and achieve its goals under variable conditions foreseen or not (Hollnagel, 2010).

4To investigate this question, an empirical study was conducted in the pediatric anesthesia services of two French hospitals. This medical specialty has the double advantage of being both an ultra-safe discipline, viewed as a pioneer in the field of patient safety, and a practice that has to cope with a high level of uncertainty and variability related to the complexity and the impredictability of the human body (Gaba, 2000; Xiao, 1994). The question is then: what are the characteristics of anesthetists’ activities which allow them to face variable situations, more or less unexpected, while achieving high levels of safety, i.e. to be resilient ?

1.2 Disturbances in anesthesia: “potential situations” and “unthought situations”

5A first study was conducted in order to characterize the disturbances that the “anesthesia system” is facing (Cuvelier & Falzon, 2010). Its goal was twofold: it was both to describe the variability of situations and their potential risks to patients and to begin to grasp the "coping strategies" implemented by anesthetists to avoid the negative consequences of this variability. The results characterize two types of critical disturbed situations endangering patients’ lives: the “potential situations” and the “unthought situations”. They show that the way anesthetists manage disruptions is not simply dependent on the nature of the disturbances themselves (often described by their frequencies or their level of complexity), but mainly depends on the anticipation of these disruptions by operators who take care of the patient in context. In other words, having or not planned and prepared the resources a priori changes the management of disturbances. Thus, two perspectives have emerged to further investigate resilience in anesthesia. One possible avenue concerns the occurrence, during the surgical operation, of an “unthought situation”, i.e an event that was not envisaged before it occurrence. In that case, the objective is to investigate the mechanisms of decisions made by anesthetists and their team to immediately manage situations that have not been foreseen as “possible” ones. A second avenue concerns the preoperative definition of an envelope of “potential situations” that could occur during the surgical intervention. This second perspective aims to describe the way in which anesthetists anticipate “potential situations” and prepare themselves to manage them. This “anticipating factor”, concerns the anesthetists’ ability to “know what to expect, that is how to anticipate developments, threats, and opportunities further into the future” (Hollnagel, 2010, p. xxxvii). This resilience factor will be developed in this paper.

2 A Study of Anticipation Processes In Anesthesia

6To investigate how anesthetists anticipate “potential situations”, we conducted a study based on field observations and on simulation-based interviews. The general principle of these interviews was to submit the same two cases on paper to several anesthetists in the presence of a researcher: a classic case, frequently encountered by pediatric anesthetists (bilateral inguinal hernia in a 6 months-old former premature) and a more complex one (syndactyly in a 2 year old child with a rare disease). These 2 clinical cases have been constructed by an expert anesthestist from real cases. The interviews were conducted using a think-aloud verbalization technique (Walker, 2005): anesthetists were presented data from the 2 cases and were asked to think aloud how they planned anesthesia. The researcher could, at any time, ask participants to explain certain points in order to obtain decision rules used by operators. Twenty anesthetists varying in experience and working in two hospitals voluntarily participated (cf. Figure 1).

7The interviews were recorded and fully transcribed for a thematic analysis of content. Following the resilience approach, the analysis did not focus on risk analysis, targeting for example only the failures anticipated by anesthetists. Rather, it aimed to understand how anesthetists prepare themselves to act, by imagining possible future situations, which include disturbances but also opportunities. Thus, data processing focused on the main decision made by anesthetists during the pre-anesthetic consultation in the 2 cases (i.e. the decision made by each of the 20 physicians, which also proved to be the most detailed decision). In the complex case, it concerns the arrangements envisaged for intubation (intubation by laryngoscopy, fiberoptic intubation or “no intubation”). In the classic case, it relates to anesthesia techniques proposed by each of the 20 physicians (general anesthesia, regional anesthesia, etc.).

3 Results

3.1 Several possible solutions and a diversity of anaesthetists’ practices

8Results show that to ensure patient safety, all anesthetists do not choose the same solution. First, in both cases, most physicians retained several possible solutions. Secondly, the various alternatives proposed in the sample are variably retained or rejected (cf.Table 1): while some solutions are consensual (eg, intubation by endoscopy in the complex case), others reveal diversified practices among anesthetists (eg, the solution “Spinal Regional Anesthesia (RA) alone” in the simple case)

Table 1: Diversity of anesthetists’pratices in the 2 clinical cases. The table shows the positioning of of the 20 anesthetists vis-à-vis the possible solutions in the 2 cases (the total of each line is equal to 20). GA = General Anesthesia; RA = Regional Anesthesia

9Thus, several solutions seem possible to manage an intervention, even for a classic case. The activity of anesthetists may, in this sense, be compared to a “design activity”: despite the existence of rules (protocols treatment established under the principles of the Evidence Base Medicine), there is not one “good solution” but several more or less satisfactory solutions, according to the trade-off made between the various criteria for solving the problem. In order to understand how anesthetists “know what to expect” and describing their ability “to address the potential” (Hollnagel et al., 2010), we need therefore to identify the criteria they take into account to develop the most suitable solution according to the singularity of situation.

3.2 Analysis of decision criteria

10The rejection or the selection of solutions by each physician is the result of a trade-off that aims to ensure the patient's anesthesia in the best conditions of comfort and safety. Thus the trade-off criteria have been identified and categorized (see example below).

Table 2: Example of the analysis of data collected

11The analysis of these decision criteria revealed that the choice of a technique rests on two types of criteria: the management of risks for the patient and the management of resources available to to handle the situation. The assessment of risks for the patient (60 risk-related criteria were mentioned in the classic case, 38 in the more complex case) refers exclusively to the management of "clinical risks" in medicine (Figure 2). It aims to ensure "maximum distance" vis-à-vis the adverse effects of the intervention for the patients’ health (respiratory risks, risk of bleeding, etc.). The evaluation of this "distance to adverse effects" by physicians is strongly referenced to their general knowledge regarding undesirable consequences of the techniques. Indeed, in all the verbalizations based on clinical risk management, the use of safety rules and of treatment protocols is very present.

12The criteria for "resources management" refers to management of "extrinsic" resources (i.e. ressources extrinsic to the operators: material, technical, organizational,) but also to the management of their "intrinsic" resources (skills, abilities, attention, cognitive resources, local rules of the trade, etc.). In our results, the resources impacting physicians' decisions concerns mainly the intrinsic resources developed by anesthetists during practice (28 resource-related criteria were mentioned in the classic case and 32 in the other one) (cf. Figure 2.). This management of resources may be individual. In that case, anesthetists take into account their own skills and knowledge in order to choose a strategy that they master (choosing a technique that is better mastered, choosing a “personally preferred” technique). The management of resources is also collective. This means that anesthetists take into account in their decision the skills of their colleagues who are likely to provide anesthesia as well as the “standard practices” adopted locally in a team1 (choosing a technique mastered by their colleagues, choosing “a “standard technique” preferred in the institution).

4 Conclusion

13Anethetists’ main objective during the planning phase is to design an envelope of "possible situations" adjusted to the resources (especially “intrinsic” resources) of the operators who are involved and who could be involved in these situations. The strategies chosen are not solely intended to be compliant ones, for which “action resources” are prepared. They must first be “controllable situations” for the team, and therefore they reflect the skills, the know-how and the individual and collective preferences of operators. To design these envelopes of "possible situations", anesthetists articulated procedural knowledge about risks and local knowledge regarding their own resources and those of their colleagues. This indicates that ultra safe performance in highly variable systems cannot be achieved only through standardization but also through the possibility and ability of the subjects to adapt their practices to their practical experience and to that of their colleagues. In other words, the development of resilience includes, in addition to the assessment of “external” risks to the patient based on protocols and rules (established by evidence-based medicine), the assessment and the management of individual and collective resources developed in each service, at the local level.

14In anesthesia, the implementation of these mechanisms of management of their own

15resources by the operators is possible thanks to two major organizational conditions. The first is that the rules are designed with the aim to empower operators and not to control them. This means firstly that “safety rules” are not "separate", "independent", or divorced from “action rules”. And secondly, it means that these rules do not replace decisions, that are necessarily localized and singular (Dien, 1998).

16Second, in order for these individual and collective resources management mechanisms to be developed:

• organizations must be designed so that they integrate and value the collective activity. This means in particular that local rules and shared work practices can be developed within each institution, at the interface between the formal protocols and the actual practice in context. In this perspective, a way to improve resilience is to enable the development of the collective activity that allows “local standard practices” to be shared (Mollo & Falzon, 2008)
• work situations must be favorable to continuous skill development. This means in particular that the working and training conditions aim at developing one’s knowledge about their own expertise (Falzon, 2008).

Acknowledgement

17This study was supported by a grant from the “Haute Autorité de Santé”.