Study of rule related behavioural migrations in an anesthesiology department

Abstract

In anesthesiology, rules, recommendations and protocols are used to coordinate behaviour in order to improve patient safety. In systems which have reached a high level of safety, migration is defined as a daily deviation of practices leading to a space of action which is different from the one defined by the rule. Our study assesses variation of behaviour before and after the introduction of a new safety rule in an anesthesiologist's team. The rule introduced by the chief of department makes it compulsory to plan and write the procedure during the pre-anaesthetic visit (day before surgery). Assessments of state before the rule, and of its implementation (immediately after introduction, 6 months later, 12 months later) were made from the anaesthetic files (n=907). Anaesthetists were blind to the study. Items linked to the rule are the inscription of the type of anaesthesia, hypnotic, opioid, muscle relaxant, hypnotic for maintenance, ways of controlling the upper airway and tube size, in the case of general anaesthesia. This study showed an erosion of the implementation six months later, with statistical significance at 12 months (p<.05). In a multivariate analysis, the factors related to a bad implementation of the rule are linked to circumstances (emergency, first anaesthesia of the day) and with the participants themselves (rule related behaviour, workload).