Méthode Orion® : analyse systémique simple et efficace des événements cliniques et des précurseurs survenant en pratique médicale hospitalière

Study on preventing adverse events in neonates (SEPREVEN)

“…First, it will consist of training in the ORION standardized RCA method, derived from aeronautics and adapted for several years to care. [ 41 ] This method allows local HCPs to perform an RCA in a simple way in their NICU setting. At the beginning of the intervention period, local HCPs (NICU senior physicians and nurses, optionally a risk manager, maximum 13 persons) will be trained in situ for 1 day to conduct a feedback meeting and perform a systemic analysis of risky events.…”

“…This study aims to evaluate the impact of combined multi-professional education on the rate of AEs in NICUs. This program combines education in a standardized RCA-like method [ 41 ] and the creation of bundles (insertion bundle, daily goals bundle, maintenance bundle) to prevent late-onset neonatal central-line-associated bloodstream infection. The outcome is measured by RCR based on a preexisting specific NICU trigger tool method.…”

Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical departments

“…The functioning of the EFC is defined in local guidelines in accordance with the framework proposed by Air France Consulting. [ 8 ] The departments can obtain methodological assistance from the quality-assurance team.…”

“…The investigation is carried out during the month following the EFC meeting by a designated person using the Orion method developed by aviation safety experts. [ 8 ] The main steps of the method are as follows: collecting data and existing guidelines describing the chronological facts that occurred before, during and after the event; describing the failures; looking for causes of errors and latent factors that could have contributed to the failures; setting up corrective actions; and writing a report of the analysis. Causes and latent factors are found in different areas such as political, organisational, working conditions, team functioning, procedures, actors and the patient.…”

“…In France, the vast majority of healthcare facilities have a similar program called the experience feedback committee (EFC). [ 8 ] The main principle of this management system is to involve the medical team in root cause analysis (RCA). The EFC members usually meet monthly to examine reported incidents that occurred in their department.…”