Belinda De Simone, MD, PhD 1,2,3
1. Department of Emergency and General Minimally Invasive Surgery, Level I Trauma Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy
2. Department of Theoretical and Applied Sciences, eCampus University, Novedrate, Como, Italy
3. Editor in Chief, Journal of Medical and Surgical Errors
Corresponding Author
Dr Belinda De Simone
Department of Emergency and General Minimally Invasive Surgery, Level I Trauma Center, Bufalini Hospital, AUSL Romagna, Via Ghirotti 256, 47521 Cesena, Italy; desimone.belinda@gmail.com; +393200771984
Abstract
Complications in general and emergency surgery are often reviewed through retrospective interpretations that do not fully account for patient-related risk, disease severity, technical difficulty, and the real clinical and organizational conditions in which care was delivered. In this setting, adverse outcomes may be too quickly reframed as evidence of professional failure, before the event has been rigorously and contextually understood. This editorial argues that the central problem is not whether complications should be examined, but how they are interpreted once they occur. When baseline risk, non-modifiable factors, system constraints, and uncertainty are ignored, complication review may shift from scientific analysis to premature attribution of blame. This distortion has consequences not only for fairness and accountability, but also for patient safety, learning culture, and the psychological well-being of surgeons, who may become second victims of evaluative processes that judge before they understand. A more mature surgical culture requires disciplined interpretation, methodological restraint, and a more honest integration of clinical complexity into the assessment of adverse events.
Keywords:
Surgical complications; General surgery; Emergency surgery; Accountability; Second victim; Moral distress; Cognitive bias; Patient safety
Introduction
Complications are an unavoidable part of surgical practice, particularly in patients with advanced disease, severe physiological derangement, frailty, hostile anatomy, or high technical complexity [1,2]. This is especially evident in emergency surgery, but it is not confined to it. Across general surgery, adverse outcomes may arise even after appropriate, timely, and technically sound care. Yet the way these events are later interpreted is often deeply problematic.
Too often, the occurrence of a complication becomes the starting point for a simplified narrative in which the outcome itself is treated as proof that something must have been done incorrectly. In this shift, the biological reality of the patient, the severity of the pathology, the technical demands of the procedure, and the contextual limits within which the surgeon acted may rapidly disappear from view. The result is not always a rigorous search for understanding, but a premature search for fault [1,2].
This editorial does not argue against accountability. On the contrary, it argues for a more serious and scientifically credible form of accountability: one that begins with reconstruction rather than accusation, distinguishes outcomes from explanations, and recognizes that complications cannot be judged fairly if they are detached from the conditions in which they developed. It also argues that when this does not happen, the burden falls not only on patients and systems, but also on surgeons themselves, who may become second victims of distorted evaluative processes [3,4].
When Surgical Complications Are Misread: Risk, Judgment, and the Burden Carried by the Surgeon
Complications are part of surgical practice. This is uncomfortable to say, but it is true. They occur in frail patients, in septic patients, in bleeding patients, in reoperative fields, in technically demanding procedures, and in operations performed under intense time pressure or limited resources. They also occur after appropriate, timely, and technically sound care. Yet once a complication happens, the tone of the discussion often changes quickly. The event itself begins to dominate the interpretation of everything that came before it. Risk is forgotten. Complexity is compressed. The biological and technical reality of the case recedes into the background, and the surgeon may be judged before anyone has truly understood what happened, in what conditions, and why.
That shift is one of the most corrosive distortions in surgical culture.
The central issue is not whether complications should be reviewed. Of course they should. Surgical practice requires accountability, honesty, and rigorous analysis. The problem is how those complications are interpreted, especially in patients who were already at substantial intrinsic risk because of non-modifiable patient factors, advanced disease, technical difficulty, or the context in which care was delivered. A frail patient with severe comorbidity, diffuse contamination, hemodynamic instability, hostile tissue planes, or delayed presentation does not enter the operating room with the same baseline probability of an uncomplicated course as a low-risk elective case. If those differences are not kept in view during retrospective review, the complication is too easily transformed into apparent proof of preventable failure [1,2].
This is where surgical judgment is often treated unfairly. In both general and emergency surgery, postoperative complications are frequently discussed as though they were self-explanatory. They are not. A complication is an outcome. It is not, by itself, an explanation. It tells us that something undesirable happened, but not whether it arose from disease biology, patient vulnerability, technical challenge, system constraints, unavoidable uncertainty, or a true preventable error. When these distinctions are blurred, the review process stops being analytical and starts becoming moralized. What should begin as an attempt to understand a clinical event becomes, instead, an implicit search for fault [1].
Healthcare systems shape surgical decisions far more than retrospective review usually admits. In real life, surgeons often work within limits they did not create and cannot immediately change: lack of staff, lack of beds, delayed diagnostics, unavailable technology, restricted operating room access, limited interventional support, fragile perioperative pathways, or local routines and unwritten internal rules that strongly influence what is actually feasible. These constraints are not secondary. They narrow decisional freedom, affect timing, and may force the surgeon to choose not between the ideal and the wrong option, but between two imperfect options under pressure. And yet, when a complication occurs, these structural conditions often disappear from the narrative. The system that silently shaped the decision steps back, and responsibility is concentrated on the individual surgeon. This is one of the deepest distortions in the evaluation of complications: systems may condition practice at every step, then vanish at the moment blame is assigned [5,6].
Emergency surgery makes this problem even more visible, because it exposes the limits of retrospective certainty more brutally than most other fields. Decisions in acute care are often made under severe time pressure, with incomplete or evolving information, unstable physiology, limited opportunity for optimization, and variable institutional readiness. In those moments, surgeons often rely on experience, pattern recognition, and rapid judgment rather than prolonged deliberation. That does not place emergency surgery outside scrutiny, but it does demand that scrutiny be proportionate to the decisional environment in which care was actually delivered. Even broader models of shared decision-making, so central in elective surgery, may be difficult to apply in the same way in urgent or unstable settings [7,8].
A major obstacle to fair evaluation is the retrospective illusion that the correct path should have been obvious. Once a complication is known, the case is often reconstructed as though its outcome had been foreseeable from the beginning. Hindsight bias, outcome bias, and attribution bias make uncertainty look smaller than it was and decision pathways more linear than they really were. Options that were reasonable in real time may appear indefensible after the fact simply because the result was poor [2,9].
The consequence is not only unfairness. It is distortion. A patient with severe sepsis, advanced disease, hostile anatomy, profound frailty, or a high-risk redo field may develop a complication despite appropriate management. But if baseline risk, disease severity, technical complexity, and organizational constraint are not explicitly taken into account, the complication may be reinterpreted as evidence that someone must have failed. This kind of interpretation is seductive because it offers emotional clarity. It is much easier to assign responsibility to one visible individual than to sit with uncertainty, interacting causes, and the reality that some bad outcomes remain biologically and clinically possible despite good care. But ease is not the same as truth [1,2,9].
This is why the language of blame is so damaging. Blame creates the illusion of resolution. It simplifies what was complex, personalizes what was multifactorial, and satisfies the institutional desire to close the narrative quickly. Yet it does so at a high cost. Once review becomes punitive before it becomes rigorous, transparency suffers. Surgeons become more guarded. Teams speak less freely. Complication analysis becomes less honest, not more. Systems that judge too quickly do not become safer. They become quieter [1,6].
There is also a human cost, and surgery has been slower than it should have been to acknowledge it. When a complication occurs, the patient suffers first, and that must remain central. But the surgeon may also carry the event long after the formal review is over. The burden is not merely legal or professional. It is moral. It is emotional. It enters memory, sleep, self-trust, and future decision-making [3,4,10].
This is where the concept of the second victim becomes essential. Surgeons can become second victims when they are forced to carry not only the sorrow of a bad outcome, but also the weight of being judged before the event has been honestly and contextually understood. When the presumption of good faith is replaced by immediate suspicion, the meaning of the complication changes. It is no longer only a clinical event requiring analysis. It becomes an accusation in search of confirmation. That experience can deepen moral distress, contribute to moral injury, and leave surgeons isolated at precisely the moment when disciplined reflection and institutional fairness are most needed [3,4,10].
None of this is an argument against responsibility. Clear technical incompetence, reckless conduct, and preventable departures from accepted standards remain indefensible. Not every complication is unavoidable, and not every adverse event deserves protection from criticism. But criticism must follow understanding, not replace it. A just surgical culture must be able to distinguish between true error, disease-driven risk, patient-related vulnerability, technical difficulty, and system constraint. If it cannot do that, then it is not practicing accountability. It is practicing simplification.
And simplification is dangerous.
What general and emergency surgery need is not less scrutiny, but better scrutiny: slower to accuse, more willing to reconstruct, more attentive to baseline risk, more honest about non-modifiable factors, more aware of structural pressures, and more disciplined in separating outcome from culpability. A complication should trigger questions before conclusions. What was the patient’s real risk profile? How advanced was the pathology? How technically difficult was the operation? What information was available at the time? Which factors were modifiable, and which were not? What constraints were imposed by the system? What was realistically possible in that setting, at that moment, for that patient?
Only after those questions have been answered should judgment begin.
That is not indulgence toward surgeons. It is fidelity to scientific integrity.
If we continue to treat complications as though they were always synonymous with fault, we will not create safer surgery. We will create quieter systems, more defensive clinicians, less honest review, and deeper moral injury. We will also continue to produce second victims while believing we are defending standards.
A mature surgical culture should be capable of something better. It should be able to hold patients at the center, pursue accountability seriously, and still resist the temptation to condemn before understanding. In high-risk surgery, that restraint is not weakness. It is rigor. And without rigor, neither fairness nor learning is possible.
Future Perspectives
The next step is not simply to call for more balanced judgment, but to build environments in which balanced judgment becomes possible. This requires practical changes in how complications are discussed, documented, and reviewed across general and emergency surgery.
First, complication analysis should become more explicitly risk-adjusted. Patient frailty, comorbidity burden, disease severity, technical complexity, reoperative setting, and structural constraints should not be treated as background information, but as essential elements of interpretation. A complication review that does not start from baseline risk is already methodologically incomplete [1,2].
Second, morbidity and mortality review processes should evolve toward more disciplined reconstruction of events. Chronology, information available at the time, realistic alternatives, and contextual limits should be examined before personal responsibility is inferred. This does not weaken standards. It strengthens their credibility [2,9].
Third, surgical institutions should recognize more openly that the system itself is often part of the causal chain. Unavailable technology, delayed diagnostics, staffing shortages, lack of beds, and unwritten local practices are not minor contextual details. They may decisively shape what can or cannot be done. A future culture of accountability must be capable of examining these structural contributors without allowing them to disappear once blame is being assigned [5,6].
Fourth, the psychological impact of adverse events on surgeons deserves greater institutional attention. The second victim phenomenon should not remain a private burden carried in silence. If systems want honest review and safer care, they must create conditions in which surgeons can reflect, speak, and learn without immediately entering a climate of suspicion [3,4,10].
Finally, future work should aim to develop more reliable and context-sensitive approaches to complication review in surgery, integrating clinical complexity, cognitive bias awareness, system-level responsibility, and professional support. The quality of surgical accountability will depend not on how quickly responsibility is assigned, but on how rigorously reality is understood [1,6,9].
Conclusions
Complications in general and emergency surgery cannot be judged fairly if they are detached from the patient’s baseline risk, the severity of the disease, the technical demands of the procedure, and the organizational conditions in which care was delivered. When these elements are ignored, complication review risks becoming an exercise in simplification rather than understanding.
The most dangerous moment is often not the complication itself, but the point at which it is too quickly translated into personal fault. That shift may distort scientific interpretation, obscure system responsibility, and place an additional moral burden on the surgeon, who may become a second victim of an evaluative process that judges before it truly understands.
A credible surgical culture must demand accountability without surrendering to premature certainty. It must be capable of rigor without reflexive condemnation, and of protecting patients without erasing complexity. Only then can complication review serve its real purpose: not symbolic blame, but honest learning, fair judgment, and safer care.
References
De Simone et al. When surgical complications are misread: risk, judgement and the burden carried by the surgeon. Journal of Medical and Surgical Errors 1:8 Mar 2026 https://doi.org/10.62538/ASIM9191
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