When Surgical Complications are Misread: Risk, Judgement and the Burden Carried by the Surgeon

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

1. Krizek TJ. Surgical error: Ethical issues of adverse events. Arch Surg. 2000;135(11):1359–1366.
2. Marsh KM, Turrentine FE, Jin R, et al. Judgment errors in surgical care. J Am Coll Surg. 2024;238(5):874–879.
3. Mackel CE, Alterman RL, Buss MK, et al. Moral distress and moral injury among attending neurosurgeons. Neurosurgery. 2022;91(1):59–65.
4. Rabin S, Kika N, Lamb D, et al. Moral injuries in healthcare workers: what causes them and what to do about them? J Healthc Leadersh. 2023;15:153–160.
5. Gramma R, Hanganu B, Arnaut O, Ioan BG. Potential conflicts of interest arising from dualism of loyalty imposed on employees of medical institutions—findings and tools for ethics management. Medicina (Kaunas). 2023;59(9):1598.
6. Øyri SF, Wiig S, Tjomsland O. Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons’ BMJ Open Qual. 2024;13(2):e002672.
7. Shinkunas LA, Klipowicz CJ, Carlisle EM. Shared decision making in surgery: a scoping review of patient and surgeon preferences. BMC Med Inform Decis Mak. 2020;20:190.
8. Niburski K, Guadagno E, Abbasgholizadeh-Rahimi S, Poenaru D. Shared decision making in surgery: a meta-analysis of existing literature. Patient. 2020;13(6):667–681.
9. Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science. 1974;185:1124–1131.
10. Zimmermann CJ, Taylor LJ, Tucholka JL, et al. Factors promoting nonbeneficial surgery and moral distress. Ann Surg. 2022;276(1):94–100.

 

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

WSES–JMESE Education & Mentorship Group 
First workshop on the pedagogical value of error, held in Antalya during the WSES World Congress”

 

In collaboration with the World Society of Emergency Surgery (WSES)

From Verona to Antalya: The Pedagogical Revolution of Error

A global journey toward mentorship, reflection, and safety in surgical education

WSES–JMESE Education and Mentorship Group (*)

 

Affiliations (*)

1. Belinda De Simone, MD; Department of Emergency and General Minimally Invasive Surgery, Level I Trauma Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy
   Department of Theoretical and Applied Sciences, eCampus University, Novedrate, Como, Italy
2. Professor Fikri Abu-Zidan, Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
3. Professor Giuseppe Borzellino, Department of Surgery, Dentistry, Pediatrics and Gynaecology, U.O. Chirurgia Generale ed Esofago e Stomaco, University of Verona, C.M. di B.go Trento, Verona, Italy
4. Professor Walter L. Biffl, Division of Trauma/Acute Care Surgery, Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California, US
5. Professor Francesca Dal Mas Department of Management, Ca’ Foscari University of Venice, Venice, Italy.
6. Professor Rifat Latifi, Department of Surgery, University of Arizona, Tucson, AZ, USA.
7. Professor Haytham M. Kaafarani, Department of Surgery, Massachusetts General Hospital, University of Harvard; Boston, Massachusetts, US
8. Professor Andrew Kirkpatrick Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada.
9. Ines Rubio, MD; Department of General Surgery, La Paz University Hospital, Madrid, Spain.
10. Professor Mehmet Erylmaz; Department of Surgery, Gülhane Education & Training Hospital, Gülhane Medical Faculty, Ankara, Turkey.
11. Kemal Rasa, MD; Department of Surgery, Anadolu Medical Center, Kocaali, Turkey.
12. Robert G. Sawyer Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA.
13. Professor Fausto Catena Department of Emergency and General Minimally Invasive Surgery, Level I Trauma Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy; Alma Mater Studiorum, University of Bologna, Bologna, Italy

 

Corresponding Author

Belinda De Simone, MD, PhDC

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

Background: Medical education has traditionally treated error as a sign of incompetence rather than as a learning opportunity. The first SIPEM ((Italian Society of Medical Pedagogy) workshop on the pedagogical role of error, held on 3 October 2025 at the University of Verona, sought to reframe error as a cornerstone of reflective learning. A few weeks later, this vision reached the international stage at the World Society of Emergency Surgery (WSES) 2025 Congress in Antalya (Türkiye), in a session co-endorsed by WSES and the Journal of Medical and Surgical Errors (JMESE).

Methods: These workshops integrated educational theory, Error-Based Learning, Reflective Practice, Constructive Alignment, and Psychological Safety, with interactive clinical cases to explore diagnostic, systemic, and strategic errors in patient care. Participants engaged through real-time polling, open discussion, and collective reflection.

Results: The clinical cases illustrated how cognitive bias, fragmented communication, and disproportionate surgical ambition contribute to error. Open, structured discussion fostered reflection rather than blame and highlighted the emotional and organizational dimensions of error. Participants identified the need for structured error analysis, faculty development, psychologically safe learning environments, and curricular integration of reflective practice and mentorship.

Conclusion: Error is not incompetence but an essential component of competence. Creating psychologically safe spaces for reflection transforms mistakes into shared knowledge. This philosophy aligns with the mission of JMESE: to convert error from a hidden stigma into a tool for education, safety, and progress. This editorial retraces the journey from Verona to Antalya, from fear to empowerment, from isolated mistakes to a shared pedagogy of growth.

Keywords: error-based learning; mentorship; psychological safety; surgical education; leadership; well-being; diversity; reflective practice

1. Verona, 3 October 2025 – The Beginning of a Conversation

The first workshop on “The pedagogical role of error in medical education” was held at the Polo Zanotto of the University of Verona, during the XXII SIPEM (Italian Society of Medical Pedagogy) National Congress.

What appeared at first to be a conventional academic session soon took a different direction. Instead of beginning with data and models, the workshop opened with a question projected on the screen:

“What comes to your mind when you think of the word error?”

Through a live word cloud, participants such as students, residents, nurses, and educators, offered terms such as fear, shame, failure, followed gradually by growth, humanity, courage, learning.

For many students, it was the first time they felt able to express openly that what they needed most from their teachers was not perfection, but safety. They reported a desire for mentors who listen without judgment, who guide rather than punish, and who treat mistakes as opportunities for growth rather than as evidence of inadequacy.

From this discussion, three levels of learning from error emerged, which subsequently shaped the pedagogical framework of the movement [1-2]:

1. Individual level: self-reflection, awareness, and emotional intelligence.
2. Team level: communication, trust, and shared resilience.
3. System level: organizational learning and cultural transformation.

The message was clear: error is inevitable and its suppression is counterproductive. “Forgive and forget” does not absolve the issue. Rather, it can affect growth. When errors are discussed within a safe environment, they become not the end of competence but its beginning.

Participants articulated concrete needs and proposals, including structured modules on error management and reflective practice in undergraduate and postgraduate curricula; safe educational environments where learners and tutors can analyze errors together without fear of blame; and regular clinical–pedagogical debriefings to turn complications into shared learning opportunities which creates networks of mentors trained in empathy and error pedagogy.

This first workshop did not aim to provide definitive answers; it planted a seed. It demonstrated that speaking about error does not weaken competence in medicine; rather, it strengthens it. Each time a physician shares an error, the silence of fear is broken and space is created for knowledge, responsibility, and compassion. As Donald Schön observed, “error is the raw material of reflection.” From that material arise competence, maturity, and genuine professional growth [3].

2. From Verona to the World – The Message Evolves

What started in Verona as a national pedagogical experiment rapidly resonated beyond Italy’s borders. The idea of transforming surgical error into a teaching tool attracted the attention of surgical educators and thoughtful leaders internationally.

When WSES and JMESE decided to co-endorse an international workshop on the same topic at the WSES 2025 Congress in Antalya, the Italian conversation on error became a global dialogue on education, and re-exploration that to “err is human” [4].

3. Antalya, November 2025 – The First International Workshop on the Pedagogical Role of Error

The session, titled “From Error to Empowerment: The Role of Mentors in Shaping Surgical Education,” brought together a distinguished international faculty. Moderated by Prof. Fausto Catena and Dr. Belinda De Simone, the workshop assembled experts from surgery, education, and ethics: Professors Haytham Kaafarani, Robert Sawyer, Fikri Abu-Zidan, Francesca Dal Mas, Kemal Rasa, Andrew W. Kirkpatrick, Rifat Latifi, and Ali Fuat Kaan Gök.

Each contributor addressed a different dimension of the same core principle: when explored with courage and empathy, error can become the foundation of excellence.

4. From Taboo to Learning Tool

Prof. Fausto Catena (University of Bologna, Italy) opened with a call for cultural change:

“Errors are inevitable in surgery. What defines us is how we respond, how we teach, and whether we have the courage to reflect.”

His talk, “Turning Surgical Mistakes into Teaching Moments,” emphasized non-punitive analysis and structured debriefing as pillars of surgical education [5].

Prof. Haytham Kaafarani (Harvard Medical School, USA) followed with “The Surgeon as the Second Victim.” He addressed moral injury, the emotional trauma clinicians experience after adverse events and highlighted the need for institutional support and structured peer assistance:

“We cannot forgive ourselves if the system does not allow us to. Support and reflection are acts of healing ”. [6]

Prof. Robert Sawyer (Western Michigan University, USA), in “Scientific Myths in Sepsis,” demonstrated how rigid dogma and uncritical application of guidelines can be as harmful as technical negligence: “When evidence becomes ideology, error becomes systemic.”[7]

Prof. Fikri Abu-Zidan (United Arab Emirates University) then turned attention to academic error, showing how methodological bias and lack of critical reflection compromise scientific validity:

“Our responsibility to patients begins long before the operating table; it begins in the data.”[8]

5. Learning from Error as a System

Prof. Francesca Dal Mas (University of Venice, Italy) introduced the concept of organizational learning, describing errors as part of an evolving “system memory” that can reshape institutional culture and behaviour [9]. Her key message was: “Institutions, like individuals, can learn if they choose transparency over blame.”

Prof. Kemal Rasa (Istanbul University, Türkiye) expanded this perspective with an honest reflection on errors in scientific publishing: plagiarism, omission, and the reluctance to publish negative results, all of which constitute intellectual error [10]. He concluded: “We must learn to fail better; silence delays truth.”

6. The Pedagogical Vision – Educational Theory Meets Surgical Practice

In the second half of the session, Dr. Belinda De Simone presented the conceptual core of the movement: the integration of established educational theory with the realities of surgical practice.

Her talk, “The Pedagogical Value of Error: From Reflection to Empowerment,” connected four key frameworks [3;11;12;13]:

1. Error-Based Learning (Metcalfe, 2017): making and correcting errors consolidates memory and deepens understanding. The “hypercorrection effect” suggests that errors made with high confidence, once corrected, are remembered best [11].
2. Reflective Practice (Schön, 1983): the distinction between reflection-in-action (thinking during practice) and reflection-on-action (retrospective analysis) underpins the transformation of experience into expertise. Without guided reflection, errors remain isolated events rather than sources of learning [3].
3. Constructive Alignment (Biggs, 1996): alignment between learning objectives, teaching activities, and assessment. Errors often reveal misalignment between what is taught, what is practiced, and what is evaluated [12].
4. Psychological Safety (Edmondson, 1999; Wawersik et al., 2023): learning from error requires a climate in which individuals feel safe to speak up. Teams that can discuss error openly tend to perform better and make fewer mistakes [13-15].

She articulated a simple but demanding proposition: “The role of the teacher is not to judge but to guide. The role of the student is to accept, to communicate, and to transform error into growth.”

De Simone also invited the audience to recognize the risks of toxic leadership, referencing Fingerhut’s description of the “surgical ego” and Ferrada’s work on emotional intelligence in surgical training [16-20].

“The greatest risk after an error is not the complication; it is the silence that follows.”

Her conclusion encapsulated the ethos of the workshop: “The best trainers do not teach perfection; they teach reflection. Mentorship turns fear into empowerment and diversity into strength.”

7. Case Reflections – When Error Meets Experience

The workshop then moved from theory to practice through clinical case discussions.

Prof. Rifat Latifi (USA/Kosovo) presented a complex case of abdominal sepsis and open abdomen management, demonstrating how communication, humility, and team coordination are crucial for successful outcomes. He emphasized that: “Error analysis is not a confession; it is an act of responsibility. It is the only way that helps a wounded surgeon to get back in the saddle”.

Prof. Ali Fuat Kaan Gök (Istanbul University, Türkiye) presented a trauma case involving intraoperative complications, highlighting the emotional tension between acting, deciding, and doubting in real time. These cases prompted discussion of non-technical skills, team dynamics, and decision-making under uncertainty [21].

8. When Systems Fail – The Kirkpatrick Lesson

In one of the most impactful moments, Prof. Andrew W. Kirkpatrick (University of Calgary, Canada) discussed the COOL Trial, a major international study on open abdomen management that faced near closure due to financial and regulatory barriers [22].

“We tried to answer a global surgical question on a global scale. What stopped us was not science; it was the system.”

He described this as an “ethical failure of the system”, a research culture that fears risk more than ignorance. His testimony illustrated that error is not limited to individuals; it can be embedded in structures and processes. Recognizing this systemic dimension is a necessary first step toward meaningful change.

9. From Reflection to Action – Rethinking How We Teach

In the final discussion, participants explored how to move from reflection to institutional change. Several priorities emerged:

1. Institutionalize reflective learning: introduce formal sessions of error analysis and debriefing in courses and residency programs, designed as guided reflections rather than disciplinary reviews.
2. Train educators in error pedagogy: develop faculty programs that address how to manage learner mistakes constructively, using feedback grounded in empathy and critical reasoning.
3. Integrate simulation and “productive failure”: use simulation not only to prevent errors, but to rehearse them in a controlled setting, followed by structured debriefing (in line with Kapur’s concept of productive failure) [23].
4. Reframe assessment culture: shift from evaluating error-free performance to assessing the learner’s capacity to recognize, analyze, and recover from mistakes.
5. Create safe reporting systems for educational errors: establish mechanisms that enable students and residents to report mistakes or near misses without fear of punishment, supporting transparency and collective improvement.

A broad consensus emerged: error must be recognized as a pedagogical opportunity, and mentorship as the primary antidote to fear. Creating psychological safety and well-being were identified as essential for both patient care and professional development. Diversity in leadership was highlighted as a resource for collective intelligence and innovation.

Participants proposed creating a WSES–JMESE International Network on Error and Mentorship, aimed at promoting research, consensus statements, and educational frameworks that integrate reflection, empathy, and well-being into surgical curricula.

10. The Vision Ahead – A New Pedagogy of Surgery

From the classrooms of Verona to the global stage of Antalya, a quiet but significant shift is underway. The movement initiated in Verona has evolved into an international call for change.

The future of surgical education will not be measured solely by the number of technically perfect procedures, but by the capacity of individuals and institutions to reflect, adapt, and include. Error should no longer be a scar to hide, but a story to share. The surgeon who reflects is not the one who never fails, but the one who never stops learning.

To err is human.
To learn from error is good medicine and progression.
To teach through error is mentorship.

The Journal of Medical and Surgical Errors: A Shared Mission

The philosophy born in Verona and expanded in Antalya resonates deeply with the mission of the Journal of Medical and Surgical Errors (JMESE), a journal dedicated to transforming how the medical community understands and communicates about error [24].

JMESE is founded on a simple but transformative premise: mistakes, when studied and shared transparently, are not failures but powerful catalysts for progress. Its mission is to: enable clinicians, educators, and researchers to analyze clinical and educational errors critically and constructively;

promote the science of error literacy, the ability to detect, discuss, and learn from mistakes at individual, team, and system levels; build bridges between patient safety, clinical education, and ethical reflection.

The workshops in Verona and Antalya embodied this mission in practice. They turned theory into dialogue, and dialogue into a shared commitment to change. They demonstrated that error can unite rather than divide, when it is addressed with honesty, empathy, and the shared goal of becoming better healers and better teachers.

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2. Coronado-Maldonado I, Benítez-Márquez MD. Emotional intelligence, leadership, and work teams: A hybrid literature review. Heliyon. 2023 Sep 20;9(10):e20356. doi: 10.1016/j.heliyon.2023.e20356. PMID: 37790975; PMCID: PMC10543214.
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