Mona Guckian Fisher discusses a risk-based and systems approach to perioperative safety. She argues that recognising human variability as both vulnerability and strength allows surgical systems to transform uncertainty from a source of threat into a foundation for resilience.
Operating theatres are high-stakes environments particularly susceptible to human error due to time pressure, complex decision-making, multidisciplinary coordination, technological intensity, and the irreversible nature of surgical interventions. The uncertainty inherent in human performance presents persistent challenges for patient safety and quality outcomes.
Despite well-established global procedures for managing sentinel events and adverse incidents, concerns about perioperative harm remain. This creates a paradox: healthcare systems now possess a sophisticated understanding of human factors, have implemented extensive policies, and have formalised processes for investigating safety events, yet catastrophic outcomes have not disappeared.
This paradox highlights a critical gap. Knowledge of safety science does not automatically translate into safer surgical systems. The challenge is not to eliminate human error — an impossible task — but to manage its uncertainty in structured, ethically grounded, and system-aware ways. This essay argues that uncertainty in perioperative human performance can be mitigated through the integration of just culture principles, risk-based thinking, identification of critical steps, human factors design, and strong regulatory accountability1,2 Safety in surgery must be understood not simply as the absence of harm but as the ongoing capacity of organisations and teams to anticipate, adapt, and respond to risk.3
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