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Ergonomics approach of the risk analysis: failure modes analysis to success mode discussion

Sylvie Thellier has defended her thesis on 12th December 2017 at INETOP, Paris (France).​

Document type > *Mémoire/HDR/Thesis

Keywords >


Authors > THELLIER Sylvie

Publication Date > 12/12/2017


Since the radiotherapy accidents which occurred in Epinal (2006) and Toulouse (2007) were detected, every French radiotherapy units have been required to set up spaces for reflection to analyze the undesirable events and to perform prospective analyses of the risks likely to be met by patients during the healing process. The present research falls within the fields of risk management and patient safety. It focuses exclusively on the implementation of the prospective approach through the Failure Mode Effects Analysis (FMEA) implementation in radiotherapy.

This research is in the field of risk management and patient safety. It aims to develop a methodology for investigating the weakening of real work of a medical team and to cope with methodological difficulties encountered by radiotherapy centers when analyzing patients’ risks incurred the therapeutic process with FMEA method. This thesis is a theoretical and empirical contribution about "safety in reflection" in discussion spaces that is distinguished within "safety in action".

This work seeks to identify a new link between safety and risk management by giving a predominant place to a methodological step often neglected: risk identification. Considering that safety of care would be depending mainly of day-to-day practices of caregivers, analysts would have to make the connection between a generic risk (eg. overexposure of patients to radiation) and its construction, its spread in the real work of healthcare team. This research proposes to elaborate this link collectively in discussion spaces classically mobilized by the sciences of management to implement a change or improve the performance of the organization and to adapt these forums to identify risks in the daily work of a radiotherapy team.

The thesis in ergonomics argues that patient safety depends on the production of a new knowledge: 1) on the complexity of the daily work of the healthcare team, 2) on success modes mobilized to reduce it and 3) on weakening conditions of these success modes. In other words, risk analysis would be a data collection process dedicated to what is really happening in the daily work and what is affecting it.

This data collection would seek to improve information held individually in relation to the complexity of the cross-functional collective work, to make visible dimensions that are difficult to access (politic, strategic, organization, context…) and to make links between complexity of work and risks incurred by patients. The aim of “spaces for sharing and exploring the complexity of work” is to improve individual and collective knowledge on the development of risky situations, to share them in the team in order to maximize the real safety.

From a theoretical perspective, we consider that the concepts of risk and risk analysis remain interesting to consider. However, the present research work suggests redefining these concepts. Regarding radiotherapy safety issues, we prefer to use the concepts of safe performance and risky performance instead of the concept of balance between rules and practices.
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