French Nuclear Safety Authority

Patient safety is a young discipline that emerged from medico-legal concerns associated with the risk of occurrence of specific and easily identifiable adverse events that were mostly associated with hospital care. In primary care however patients are managed over long periods of time and the safety issues that arise are likely to be of a very different character. We have earlier suggested that we should recast patient safety as the management of risk over time; this perspective may be better adapted to the longer time scales of primary care.

We have put forward a series of arguments culminating in the idea that patient safety should be viewed as the management of risk over time. We have suggested that healthcare could draw on a much wider repertoire of strategies and interventions to manage risk and enhance safety. This has been a book of ideas and argument but we hope that these are both rooted in practice and practical application. In this chapter we first consider some of the more immediate implications as we see them and then consider the form a longer term exploration and development might take.

Patient safety has evolved and developed in the context of hospital care. The understanding we have of the epidemiology of error and harm, the causes and contributory factors and the potential solutions are almost entirely hospital based. Safety in home care is likely to require different concepts, approaches and solutions. Safety in this context has however been barely addressed and yet care provided in the home will soon become the most important context for healthcare delivery.

The developments described in the previous chapters are required because our present vision of safety is not adequate for the challenges we face. Our arguments for these developments rest on analyses of the nature of safety in healthcare as it is delivered today. However, as is well known, healthcare is changing rapidly and there are many new opportunities, pressures and challenges. We believe that these coming changes will have further implications for how safety is understood and practiced which will increase the urgency and importance of the transition to a broader vision.

Safety in healthcare is a constantly moving target. As standards improve and concern for safety grows, we come to regard an increasing number of events as patient safety issues. In this respect, healthcare differs from almost all other safety-critical industries. What we regard as harm in, for instance, civil aviation remains the same whatever advances may occur in aviation technology or practice. In contrast, innovation and improving standards in healthcare alter our conceptions of both harm and preventability. In the 1950s, many complications of healthcare were recognised, at least by some, but largely viewed as the inevitable consequences of medical intervention.1 Over time, certain types of incidents come to be seen as both unacceptable and potentially preventable. The clearest example in recent times is healthcare-associated infections, which in the 1980s were still regarded as unfortunate, but inevitable. With increased understanding of underlying processes, mechanisms of transmission and methods of prevention, coupled with major public and regulatory pressure, such infections are now seen as patient safety issues.2 The list of ‘never events’ put forward in various countries, such as wrong-site surgery, is similarly an assertion that certain types of failure cannot be tolerated.3 In the last 10 years, as more types of harm have come to be regarded as preventable, the perimeter of patient safety has expanded. We could now include pressure ulcers, …

Research suggests that browsing clinical guidelines in a linear format is difficult for users. One national producer of clinical guidelines (HAS, the French National Authority for Health) has recently developed a new document format designed to improve accessibility. It is a limited-depth hypertext structurally constrained so that all information lies within two clicks of a central index ('reco2clics'). In the following paper, we introduce an authoring tool which converts full-length clinical guidelines to the 'reco2clics' format. Alongside routine editorial operations, this tool supports dynamic document restructuring, a complex operation using text segmentation algorithms and deontic analysis.

BackgroundIn France, one in five women gives birth by caesarean section and in almost half of cases, caesarean section is planned. Elective caesarean is a subject of controversy (some indications, maternal request) and its practice is marked by highly disparities in the country.ObjectiveTo improve the relevant practice of elective caesarean.MethodsIn a short time, an integrative process was developed with systematic reviews, working group of multidisciplinary health professionals and patients, focus group, implementation network.Results For serving the identified needs, we updated guidelines, developed information for/with the patients, and produced implementation tools adapted to the different medical indications. Clinical situations which may lead to a planned caesarean section are varied and complex. For each of them, we redefined the indications of caesarean section or vaginal delivery. For elective caesarean, women should be informed as soon as possible, with provided developed tools, to enable an informed discussion with the caregiver and to improve the maternal experience. The decision elements to report in the medical record were defined and a set of tools with the approach ‘patient journey’ developed: clinical pathways, evaluation criteria of relevance or grids, examples of improvement actions and indicators. In February 2013, more than 183 establishment of health were engaged in the programme.Conclusions We provided a set of implementation tools to improve the relevance of planned caesarean section. The continuous feedback by the different actors will allow enriching electronic version tools and sharing knowledge in the field, thus enabling a continuous improvement process.

Un exercice inédit a été mené en Europe : sur la base d’un cahier des charges commun, 140 réacteurs nucléaires ont fait l’objet de tests de résistance dont les résultats, soumis à un audit croisé, ont abouti à des recommandations qui se déclinent au niveau national et se traduiront par des mesures concrètes de renforcement de la sûreté.

L’ASN assure le contrôle de la sûreté nucléaire et de la radioprotection et contribue à la gestion des situations d’urgence radiologique en France et à l’information du public. L’ASN s’est impliquée dans la gestion de la situation de crise liée à l’accident de Fukushima alors même que l’accident n’est pas survenu en France. L’ASN a tiré les premiers enseignements en matière de sûreté nucléaire, en particulier sur l’importance vitale de l’alimentation électrique externe et de la source froide d’un réacteur. Par ailleurs, l’ASN met en place les évaluations complémentaires de sûreté en France et contribue activement au processus européen. Enfin, l’ASN a tiré plusieurs leçons pour elle-même dans la gestion d’une crise de grande ampleur.

Over the last 5 years France gained a feedback on its NORM industries situation. Regulation imposes to the operators to assess effective doses for workers and members of the public. Theses data were used to update the list of industrial sectors to be regulated for NORM use or storage.