Accountability in emergency surgery: moving beyond blame toward high reliability: a WSES-JMESE position paper

Background Emergency surgery is characterized by clinical uncertainty, time pressure, evolving information, physiological instability, and substantial variability in available resources. In this setting, adverse outcomes may occur despite timely and appropriate care and should not automatically be interpreted as evidence of professional failure. Nevertheless, surgeons may be exposed to retrospective, outcome-driven, and overly individualized attribution of blame when the complexity of the original decisional environment is insufficiently considered. A structured framework is therefore needed to support fair, proportionate, and learning-oriented accountability in emergency surgical practice. Methods This evidence-informed position paper was developed through a structured multidisciplinary review of literature from patient-safety science, cognitive psychology, medical ethics, health- systems research, surgical professionalism, and high-reliability organization theory, complemented by iterative expert discussion within the World Society of Emergency Surgery– Journal of Medical and Surgical Errors working group. The literature was synthesized narratively to identify the principal contextual, cognitive, ethical, professional, and organizational domains relevant to fair accountability and adverse-event review in emergency surgery. The resulting statements were framed as ungraded evidence-informed Good Practice Statements according to the GRADE framework rather than clinical practice recommendations based on comparative effectiveness evidence. Results The synthesis identified seven interrelated principles for fair accountability in emergency surgery: contextual proportionality; distinction between accountability and blame; mitigation of hindsight, outcome, and attribution bias; recognition of distributed responsibility across individuals, teams, and systems; protection of professional integrity; procedural fairness and institutional responsibility; and application of high-reliability principles. Particular attention is given to the dynamic and time-dependent nature of emergency surgical decision-making, the incomplete representation of clinical reasoning in contemporaneous documentation, the limitations of population-based scoring systems and benchmarks, and the influence of resource availability on feasible treatment options. These principles were integrated into a structured framework for adverse-event review aimed at supporting proportionate analysis of adverse outcomes and avoiding premature attribution of individual blame when harm reflects interacting clinical, cognitive, team-level, and system-level factors. Conclusions Accountability in emergency surgery should evaluate decisions according to the information, physiological condition, reasonable alternatives, and resources available at the time of care. Contextualization should not eliminate individual responsibility; rather, it should make responsibility attribution more accurate, proportionate, and fair. A bias-aware, procedurally fair, and high-reliability approach can protect surgeons from premature, punitive, outcome-driven blame while preserving legitimate accountability for unsafe practice, reckless conduct, or misconduct. Such a framework may strengthen patient safety, professional integrity, organizational learning, and public trust.