Surgical safety depends on systems, not blame

This review argues that preventing surgical harm requires linking event reporting, structured analysis, and ongoing performance review within a just culture—not treating each adverse event as an isolated failure.

• Nonpunitive reporting can surface patterns; root-cause and apparent-cause analyses should guide corrective action rather than assign blame.
• Ongoing and focused professional practice evaluations can help identify provider performance gaps over time.

This is a systems framework, not evidence that these processes reduce complications by a measured amount; the review reports no comparative outcomes.