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Master Thesis

Le retour d'expérience, une étape de la sécurisation du circuit du médicament‎

Abstract : Since the law of 9 August 2004, medical establishments are required to declare undesirable events which arise during medical procedures associated with diagnoses, treatments or preventive actions. In addition to the obligation of declaration, the central health authority recommends that the causes of errors be investigated and analysed in order to guard against their recurrence. In 2007 at the Reine Blanche Clinic in Orleans a multidisciplinary feedback committee was set up. This committee is known by its acronym CREX (Comité de Retour d'Expérience). Its task was to undertake in depth systematic analyses of incidents, accidents and near-accidents which occurred in the medication circuit. Once the cause of the errors had been identified, corrective action could be proposed. In order to carry out this task effectively we made use of methodology used in the domain of aeronautics with the aim of improving security. Several difficulties were encountered in the course of carrying out this experiment, but in the end the fears of mediatic attention and of the opinions of others, and the reticence to exposing oneself to investigation, were overcome. The increasing number of declarations made reflected the recognition, by the professionals involved, of the difference between a fault and a mistake. The appreciation of other teams, and the interest shown in the experiment at both the regional and the national level provided strong encouragement to the CREX teams. The imminent publication by the minister of an opposable system of refence for the management of security should ensure the perpetuity of this system by placing it in a regulatory framework.
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Master Thesis
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Contributor : Jean-Hugues Morneau <>
Submitted on : Wednesday, July 9, 2014 - 4:13:45 PM
Last modification on : Tuesday, May 11, 2021 - 11:36:17 AM
Long-term archiving on: : Thursday, October 9, 2014 - 12:39:16 PM


  • HAL Id : dumas-01021655, version 1


Nicole Duchassin Mabs. Le retour d'expérience, une étape de la sécurisation du circuit du médicament‎. Sciences pharmaceutiques. 2009. ⟨dumas-01021655⟩



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