Surgery
Managing the uncertainty of human error
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
Reframing human error in surgery For much of modern surgical history, adverse events were framed primarily as individual failures. The dominant assumption was that if clinicians were competent, attentive, and compliant with procedures, harm would not occur. When harm did occur, investigations frequently focused on identifying the individual responsible. This person-centred model aligned with a professional culture that emphasised autonomy, expertise, and personal accountability.4 Safety science has fundamentally challenged this perspective. In Just Culture, Dekker argues that explanations of failure must reconcile accountability with organisational learning. He distinguishes between retributive responses, focused on punishment, and restorative responses, focused on repairing trust and improving systems. Understanding error requires adopting what Dekker calls the “inside view”: examining how decisions made sense to
practitioners at the time, given the information, pressures, and constraints they faced.1 In perioperative environments, this distinction
is crucial. Decisions that appear negligent in hindsight may have been reasonable in real time under conditions of cognitive load, time pressure, and incomplete information. Surgical practice occurs within complex socio-technical systems involving surgeons, anaesthetists, nurses, operating department practitioners, sterile services, equipment suppliers, and digital systems. Patient variability – anatomical, physiological, and pathological – adds further unpredictability.3 Within such complexity, errors rarely result
from isolated incompetence. Rather, they emerge from interactions between people, technologies, organisational processes, and environmental conditions. Recognising this systemic nature of error shifts the focus of safety improvement from blaming individuals toward designing safer systems.4
From blame to a just culture Managing uncertainty requires a cultural shift away from reflexive blame. A just culture recognises that unsafe actions are not morally equivalent and that responses should be proportionate to behaviour. Human error refers
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