Les erreurs humaines en anesthésie

Human errors in anesthesia - with due respect to the French-speaking tradition, human error is studied in field work, here in anesthesia. The authors specify the social context, compare the process of anesthesia to a continuous process, present a cognitive analyse of the task, emphasizing temporal characteristics and cognitive demands regarding the cognitive aspects of human behavior.
Referring to the dictinction made by Hollnagel (1991) between reliability, robustness and adaptiveness of the system (man and machine), they present and analyse some human errors which reveal the importance of variation elements and the dynamic dimension of the environment. Influenced by Time Psychology, they postulate the existence of different systems of temporal reference and of external synchronizers connected to these systems, which would allow an individual to adaptively respond to the demands for synchronization in the face of events and actions whose evolutions cannot be calibrated in clock time. Inadequate systems of temporal reference and the absence of synchronizers can make this adaptation to the evolution and the dynamicity of the environment fail. The prevention integrates different measures (technological, ergonomic, social, organizational, of expertise development, etc.) and relies on collection and in-depth analysis of human error. This paper is dedicated to J. Leplat.