Titre : Error, cognitive bias, tunnel effect and chirurgical teamwork: aeronautics lessons for peri-operative care safety 

Auteurs : Patrick Houvet,  

Revue : Cognitive Engineering 

Numéro : Issue 1 

Volume : 8 

Date : 2025/10/8 

DOI : 10.21494/ISTE.OP.2025.1354 

ISSN : 2517-6978 

Résumé : This article aims to articulate the epidemiology of EIAS / EIGS and systemic failure models (Reason, Vincent) to guide prevention, recovery, and organizational learning in healthcare, with a particular focus on perioperative care. It outlines the error→incident→accident trajectory driven by cognitive limits, fatigue, stress, and communication failures. Cognitive biases and attentional tunneling are addressed through debiasing tactics. CRM/TEM frames team performance via briefings, adaptive leadership, closed-loop communication, and sterile-cockpit discipline. Checklists (WHO, SURPASS) and structured handovers (I-PASS/SBAR) deliver documented reductions in mortality and complications. The 2024 London Protocol refreshes RCA/ALARM and embeds a just-culture, learning-oriented REX. A Safety-II/HRO stance builds “safe-to-fail” organizations, sensitive to operations and deferent to expertise. Digital enablers (CPOE/CDS, BCMA, emergency manuals, OR Black Box, early-warning/AI) strengthen detection, traceability, and learning. 

Éditeur : ISTE OpenScience