Scenario Analysis: This scenario is professionally challenging because it requires a nuanced understanding of the examination board’s policies regarding candidate performance and progression. Balancing the need for rigorous assessment with fairness to candidates who may have faced extenuating circumstances demands careful judgment. Misinterpreting or misapplying these policies can lead to unfair outcomes for candidates and undermine the integrity of the examination process. Correct Approach Analysis: The best professional practice involves a thorough review of the examination board’s official blueprint, specifically focusing on the sections detailing scoring methodology and retake policies. This approach is correct because it directly addresses the established framework governing the examination. Adherence to these documented policies ensures consistency, fairness, and transparency in the assessment process. It provides a clear, objective basis for decision-making, minimizing subjective bias and ensuring that all candidates are evaluated against the same criteria. This aligns with the ethical obligation to uphold the standards and procedures set forth by the certifying body. Incorrect Approaches Analysis: One incorrect approach is to rely on anecdotal evidence or informal discussions with other examiners regarding retake decisions. This is professionally unacceptable because it bypasses the official, documented policies. Such an approach introduces subjectivity and inconsistency, potentially leading to disparate treatment of candidates. It fails to uphold the regulatory requirement for standardized assessment procedures. Another incorrect approach is to make retake decisions based solely on the perceived effort or perceived improvement of a candidate, without reference to the specific scoring thresholds or retake criteria outlined in the examination blueprint. This is ethically flawed as it prioritizes subjective impressions over objective, pre-defined standards. It deviates from the principle of merit-based assessment and can be perceived as arbitrary. A further incorrect approach is to assume that a candidate’s previous examination performance automatically dictates their eligibility for a retake, without consulting the current examination’s specific retake policy. This is professionally unsound because examination policies can be updated, and each examination cycle may have distinct criteria. Failing to consult the current policy risks misapplying outdated rules, leading to procedural errors and potential challenges to the examination’s validity. Professional Reasoning: Professionals should approach such situations by first identifying the governing regulatory framework and its specific provisions related to assessment and candidate progression. This involves consulting official documentation, such as examination blueprints, policy manuals, and guidelines. When faced with ambiguity or a unique candidate situation, the professional decision-making process should involve seeking clarification from the examination board’s administrative or policy-setting body. This ensures that decisions are grounded in established rules, are applied consistently, and uphold the integrity of the examination process.

This scenario is professionally challenging because it requires balancing the immediate need for patient care with the imperative to maintain robust governance and risk management frameworks. The core tension lies in ensuring that urgent clinical decisions do not inadvertently bypass or undermine established protocols for patient safety and resource allocation, which are critical for long-term service quality and compliance. Careful judgment is required to navigate the pressures of an emergency while upholding the principles of good governance. The best approach involves a structured, documented process that prioritizes patient safety while adhering to established governance. This includes immediately assessing the patient’s clinical urgency, consulting with relevant senior colleagues or the on-call governance lead to discuss the proposed deviation from standard protocol, and documenting the rationale for any expedited decision-making. This approach is correct because it aligns with the principles of clinical governance, which mandate accountability, transparency, and continuous improvement. It ensures that even in urgent situations, decisions are justifiable, auditable, and contribute to learning. Regulatory frameworks often emphasize the importance of clear communication channels and documented decision-making processes, particularly when patient care deviates from standard pathways, to ensure patient safety and to facilitate post-incident review. An incorrect approach would be to proceed with the advanced surgical procedure without seeking appropriate governance oversight or consultation, even if the patient’s condition appears critical. This fails to uphold the principle of accountability within the governance framework. It bypasses the established checks and balances designed to ensure that all procedures, especially advanced ones, are performed by appropriately credentialed staff in suitable settings, and that potential risks have been thoroughly evaluated. Such an action could lead to significant regulatory breaches if the procedure is outside the scope of practice or if unforeseen complications arise without proper support or documentation. Another incorrect approach is to delay the procedure significantly to complete a full, formal governance review, even if the patient’s condition is deteriorating rapidly. While governance is crucial, an overly bureaucratic or inflexible adherence to process in an acute emergency can directly endanger the patient. This approach fails to recognize the dynamic nature of clinical emergencies and the need for proportionate governance responses. Ethical considerations and patient well-being must take precedence when immediate life-saving or limb-saving intervention is required, and governance processes should be adaptable to such circumstances, not a barrier to essential care. Finally, an incorrect approach would be to rely solely on informal verbal agreements with colleagues without any written documentation or formal notification to the relevant governance bodies. While collegial support is valuable, this lack of formal record-keeping undermines transparency and accountability. It makes it difficult to review the decision-making process, learn from the experience, or defend the actions taken if questions arise later. This approach is contrary to the principles of good governance, which require clear audit trails and documented evidence of decision-making and oversight. Professionals should adopt a decision-making framework that integrates clinical urgency with governance requirements. This involves: 1) Rapid clinical assessment of the patient’s needs. 2) Immediate consultation with senior colleagues or the designated governance lead to discuss the situation and proposed course of action. 3) Documenting the clinical rationale and the governance consultation process. 4) Ensuring that the decision aligns with the spirit and intent of governance policies, even if a minor deviation from strict procedure is necessary due to the emergency. This framework ensures that patient safety remains paramount while maintaining professional accountability and adherence to regulatory expectations.

Scenario Analysis: This scenario presents a common challenge in operative settings: balancing the need for efficient and effective surgical intervention with the paramount importance of patient safety, particularly concerning energy device usage. The professional challenge lies in the surgeon’s responsibility to not only possess technical skill but also to critically assess and manage potential risks associated with advanced surgical tools. This requires a proactive approach to safety, informed by current best practices and regulatory expectations, rather than a reactive one. Correct Approach Analysis: The best professional practice involves a comprehensive pre-operative assessment and intra-operative vigilance regarding energy device safety. This includes a thorough review of the patient’s anatomy, potential risks specific to the planned procedure, and confirmation that all necessary safety checks for the chosen energy device have been completed. During the procedure, continuous monitoring of device function, appropriate tissue selection for energy application, and adherence to established safety protocols (e.g., ensuring insulation integrity, using smoke evacuation) are critical. This approach aligns with the fundamental ethical principle of non-maleficence (do no harm) and the regulatory imperative to maintain the highest standards of patient care and safety, as often mandated by professional bodies and healthcare institutions. It demonstrates a commitment to risk mitigation through informed decision-making and diligent execution. Incorrect Approaches Analysis: One incorrect approach involves proceeding with the energy device without a specific pre-operative risk assessment for its use in the context of the patient’s unique anatomy and the planned procedure. This fails to proactively identify potential complications, such as inadvertent thermal injury to adjacent structures, and neglects the ethical duty to anticipate and prevent harm. It also contravenes guidelines that emphasize thorough pre-operative planning for all aspects of surgery, including the use of specialized equipment. Another unacceptable approach is to rely solely on the device manufacturer’s default settings without considering the specific surgical context or patient factors. This overlooks the surgeon’s responsibility to tailor the use of technology to the individual patient and the operative field. It can lead to suboptimal energy delivery, increased risk of tissue damage, and a failure to adhere to best practices that advocate for personalized surgical technique. A further flawed approach is to disregard intra-operative alerts or unusual device performance, assuming they are minor technical glitches. This demonstrates a lack of critical appraisal and a failure to prioritize patient safety over perceived expediency. Ignoring such signals can have severe consequences, including equipment malfunction leading to patient injury, and violates the professional obligation to ensure the safe and effective use of all surgical instruments. Professional Reasoning: Professionals should adopt a systematic approach to surgical safety, particularly with energy devices. This involves a pre-operative checklist that includes a specific review of energy device safety considerations relevant to the planned procedure and patient. Intra-operatively, a mindset of continuous vigilance is essential, where any deviation from expected device performance or patient response triggers an immediate pause and reassessment. This proactive and attentive approach, grounded in ethical principles and regulatory expectations for patient safety, forms the bedrock of responsible surgical practice. QUESTION: Benchmark analysis indicates that the use of energy devices in complex foot and ankle surgery carries inherent risks. Considering operative principles and instrumentation safety, which of the following represents the most robust approach to mitigating these risks during a challenging osteotomy procedure requiring electrocautery? OPTIONS: a) A comprehensive pre-operative assessment of patient-specific anatomy and potential risks related to electrocautery use, coupled with diligent intra-operative monitoring of the device and its application to tissues. b) Proceeding with electrocautery based on the surgeon’s extensive experience, assuming standard safety protocols are sufficient for the planned osteotomy. c) Relying exclusively on the electrocautery device’s pre-set energy levels, without specific consideration for the surrounding soft tissues or bone density during the osteotomy. d) Continuing electrocautery use even if intermittent smoke evacuation issues arise, prioritizing the completion of the osteotomy without interruption.

This scenario is professionally challenging due to the inherent risks associated with advanced surgical procedures, the potential for unexpected complications, and the critical need for timely and appropriate management to ensure patient safety and optimal outcomes. The surgeon must balance the urgency of the situation with the need for thorough assessment and adherence to established protocols. Careful judgment is required to differentiate between expected post-operative sequelae and true complications, and to initiate the correct management pathway without delay. The best approach involves immediate, comprehensive clinical assessment and diagnostic imaging to accurately identify the nature and extent of the suspected complication. This is followed by prompt consultation with relevant specialists and the initiation of a tailored management plan, which may include conservative measures, interventional radiology, or further surgical intervention. This approach is correct because it prioritizes patient safety by ensuring a rapid, evidence-based response to a potentially serious complication. It aligns with ethical principles of beneficence and non-maleficence, as well as professional guidelines that mandate prompt and effective management of surgical complications. Adherence to institutional protocols for complication management is also a key regulatory and ethical imperative. An incorrect approach would be to delay definitive management based on a subjective assessment of patient stability without objective diagnostic confirmation. This failure to promptly investigate a suspected complication could lead to delayed treatment, exacerbation of the condition, and poorer patient outcomes, violating the duty of care. Another incorrect approach would be to proceed with a different surgical procedure without a clear diagnosis of the complication or a consensus on the best course of action. This demonstrates a lack of systematic problem-solving and could introduce further risks and complications. Finally, an incorrect approach would be to solely rely on anecdotal experience or the opinions of non-specialist colleagues without seeking expert consultation or utilizing diagnostic tools. This disregards established best practices and potentially compromises the quality of care. Professionals should employ a systematic decision-making process when faced with suspected surgical complications. This involves: 1) Recognizing deviations from expected post-operative recovery. 2) Conducting a thorough clinical assessment, including vital signs, pain assessment, and examination of the surgical site. 3) Utilizing appropriate diagnostic modalities (e.g., X-ray, CT scan, ultrasound) to confirm or refute the suspected complication. 4) Consulting with relevant specialists (e.g., vascular surgeon, infectious disease specialist, radiologist) based on the suspected complication. 5) Developing and implementing a multidisciplinary management plan, documenting all decisions and actions. 6) Continuously monitoring the patient’s response to treatment and adjusting the plan as necessary.

This scenario presents a professionally challenging situation due to the inherent complexity of managing a polytraumatized patient with a suspected ankle fracture in a critical care setting. The challenge lies in balancing the immediate need for resuscitation and stabilization of life-threatening injuries with the definitive management of a potentially limb-threatening extremity injury. Careful judgment is required to prioritize interventions, ensure patient safety, and adhere to established protocols, all while considering the dynamic nature of critical care. The best professional approach involves a systematic and evidence-based assessment of the patient’s overall condition, prioritizing life-saving measures before focusing on the ankle injury. This entails a rapid primary survey (Airway, Breathing, Circulation, Disability, Exposure) to identify and manage immediate threats to life. Once the patient is hemodynamically stable and major injuries are addressed, a secondary survey, including a focused assessment of the injured limb, can be performed. This approach aligns with established trauma resuscitation protocols, such as the Advanced Trauma Life Support (ATLS) guidelines, which emphasize the ABCDE approach. Ethically, this prioritizes the patient’s survival and well-being by addressing the most critical issues first, preventing further harm, and ensuring a structured, evidence-based management plan. An incorrect approach would be to immediately focus on the ankle fracture, perhaps by attempting reduction or imaging before ensuring the patient is stable. This would be a significant regulatory and ethical failure. It disregards the fundamental principles of trauma care, potentially diverting critical resources and attention from life-sustaining interventions. Such an action could lead to deterioration of the patient’s overall condition, exacerbation of shock, or missed diagnoses of other life-threatening injuries, violating the duty of care and the principle of non-maleficence. Another incorrect approach would be to delegate the initial assessment and resuscitation of a polytraumatized patient to junior staff without adequate senior supervision or a clear plan. While teamwork is essential, the responsibility for overall patient management in a critical care setting rests with the senior clinician. Failure to provide appropriate oversight or a structured management plan constitutes a breach of professional responsibility and could lead to errors in judgment or missed critical findings, contravening professional standards and potentially leading to adverse patient outcomes. A further incorrect approach would be to delay definitive management of the ankle fracture indefinitely, even after the patient is stabilized, due to perceived complexity or lack of immediate resources. While initial stabilization is paramount, prolonged delay in addressing a significant fracture can lead to complications such as malunion, nonunion, compartment syndrome, and increased pain and disability. This would represent a failure to provide comprehensive care and could be considered a breach of the duty to manage all significant injuries appropriately once the patient’s life is no longer in immediate peril. The professional decision-making process for similar situations should involve a structured, systematic approach. This begins with a rapid, thorough assessment of the patient’s physiological status, prioritizing life threats. Communication and teamwork are crucial, with clear roles and responsibilities established. Continuous reassessment of the patient’s condition is vital, allowing for adjustments to the management plan as needed. Evidence-based guidelines and protocols should inform all decisions. Finally, a clear plan for definitive management of all injuries, including the ankle fracture, should be developed and implemented once the patient is stabilized.

Scenario Analysis: This scenario presents a common challenge in advanced practice foot and ankle surgery: balancing the desire to offer innovative treatments with the paramount duty to patient safety and informed consent. The professional challenge lies in accurately assessing the risks and benefits of a novel surgical technique, particularly when it deviates from established protocols, and ensuring the patient fully comprehends these implications before proceeding. This requires a high degree of clinical judgment, ethical integrity, and adherence to regulatory standards for patient care and research. Correct Approach Analysis: The best professional practice involves a comprehensive, multi-faceted risk assessment that prioritizes patient safety and informed consent. This includes a thorough review of existing literature on the novel technique, consultation with experienced colleagues or mentors, and a detailed discussion with the patient about the potential benefits, known risks, and alternative established treatments. Crucially, it necessitates obtaining explicit, documented informed consent that clearly outlines the experimental nature of the procedure, potential complications, and the absence of long-term outcome data. This approach aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, and is supported by regulatory frameworks that mandate informed consent and responsible innovation in healthcare. Incorrect Approaches Analysis: Proceeding with the novel technique after a cursory review of limited anecdotal evidence, without consulting peers or thoroughly discussing the experimental nature and risks with the patient, represents a significant ethical and regulatory failure. This approach neglects the duty of care by not adequately investigating potential harms and bypasses the fundamental requirement of informed consent, potentially exposing the patient to undue risk without their full understanding. Opting for the novel technique solely based on its perceived technological advancement or potential for a quicker recovery, without a rigorous risk-benefit analysis or comprehensive patient discussion, is professionally unacceptable. This prioritizes innovation over patient well-being and fails to uphold the principles of evidence-based practice and patient autonomy. The absence of a thorough risk assessment and informed consent process violates regulatory expectations for patient safety and ethical medical practice. Performing the novel technique after a brief discussion with the patient that highlights only the potential benefits, while downplaying or omitting the significant unknowns and potential risks associated with an unproven method, is a clear breach of ethical and regulatory obligations. This constitutes a failure to obtain truly informed consent, as the patient is not presented with a balanced and complete picture of the procedure’s implications. Such an approach undermines patient trust and exposes the practitioner to significant professional liability. Professional Reasoning: Professionals should adopt a systematic decision-making process when considering novel surgical techniques. This process should begin with a thorough literature search and evidence appraisal. Next, consultation with experienced peers and mentors is essential to gain diverse perspectives and identify potential pitfalls. A comprehensive risk-benefit analysis, considering both short-term and long-term outcomes, must be conducted. Finally, and most critically, a detailed and transparent discussion with the patient is required, ensuring they understand the experimental nature of the procedure, all potential risks and benefits, and available alternatives, culminating in documented informed consent.

This scenario is professionally challenging because it involves balancing the surgeon’s experience and judgment with the need for objective, evidence-based risk assessment and patient safety protocols. The performance metrics highlight a potential deviation from standard practice, necessitating a review of the operative planning process. Careful judgment is required to ensure that individual patient factors are thoroughly considered without compromising established safety standards. The best approach involves a comprehensive pre-operative assessment that integrates objective data with clinical judgment. This includes a detailed review of imaging, patient history, co-morbidities, and any specific biomechanical considerations relevant to the planned procedure. Crucially, this assessment must be documented, and any identified risks should be proactively addressed through tailored surgical techniques, appropriate instrumentation, and a clear post-operative management plan. This aligns with ethical principles of beneficence and non-maleficence, ensuring the patient receives the highest standard of care and that potential complications are minimized. Regulatory frameworks in surgical practice emphasize thorough pre-operative evaluation and risk stratification as fundamental to patient safety. An approach that relies solely on the surgeon’s subjective assessment of risk, without a structured framework for identifying and mitigating potential complications, is professionally unacceptable. This can lead to overlooking critical factors that could impact patient outcomes and may not align with established best practices or regulatory expectations for due diligence in operative planning. Another unacceptable approach is to proceed with surgery without a clear, documented plan for managing identified risks. This demonstrates a failure to adequately prepare for potential intra-operative or post-operative challenges, potentially jeopardizing patient safety and contravening the principles of responsible surgical practice. Finally, an approach that prioritizes speed or convenience over a thorough risk assessment, perhaps by skipping certain pre-operative checks or consultations, is also professionally unsound. This disregards the fundamental ethical and regulatory imperative to place patient well-being above all other considerations. Professionals should employ a systematic decision-making process that begins with a thorough understanding of the patient’s condition and the proposed intervention. This involves actively seeking out and integrating all relevant data, engaging in critical thinking about potential risks, and developing a robust plan to mitigate those risks. Regular review of performance metrics and adherence to established protocols are essential components of continuous quality improvement and patient safety.

Scenario Analysis: This scenario presents a professional challenge related to the effective and compliant preparation for an advanced practice examination. The core difficulty lies in balancing the need for comprehensive knowledge acquisition with the efficient use of limited preparation time, while adhering to ethical standards of professional development and avoiding misleading or inadequate resources. Careful judgment is required to select resources that are both authoritative and relevant to the specific demands of the Comprehensive Mediterranean Foot and Ankle Surgery Advanced Practice Examination. Correct Approach Analysis: The best professional practice involves a structured approach that prioritizes official examination guidelines, recommended reading lists from reputable professional bodies, and peer-reviewed literature directly relevant to Mediterranean foot and ankle surgery. This approach ensures that preparation is aligned with the examination’s scope and depth, drawing from authoritative sources that reflect current best practices and evidence-based medicine. Adherence to these resources demonstrates a commitment to rigorous, evidence-based learning and professional integrity, aligning with the ethical imperative to prepare competently for advanced practice. Incorrect Approaches Analysis: Relying solely on outdated textbooks or general surgical forums presents significant regulatory and ethical failures. Outdated materials may not reflect current surgical techniques, diagnostic criteria, or treatment protocols, leading to a deficiency in knowledge that could compromise patient care if the candidate were to practice based on this information. General surgical forums, while potentially offering anecdotal insights, lack the rigorous peer review and authoritative backing of academic literature or professional guidelines, making them an unreliable and potentially misleading source of information. Furthermore, prioritizing resources based on popularity or ease of access over their academic rigor and relevance to the specific examination’s focus is an inefficient and potentially unethical approach to professional development, as it risks superficial learning rather than deep, evidence-based understanding. Professional Reasoning: Professionals should adopt a systematic approach to examination preparation. This involves first identifying the official examination blueprint and syllabus. Subsequently, they should consult recommended reading lists provided by the examination board or relevant professional societies. A critical evaluation of available resources should then be undertaken, prioritizing peer-reviewed journals, authoritative textbooks, and guidelines from recognized Mediterranean foot and ankle surgery associations. A timeline should be developed that allocates sufficient time for in-depth study of each topic area, incorporating regular self-assessment and practice questions. This structured, evidence-based approach ensures comprehensive and compliant preparation.

This scenario is professionally challenging due to the inherent risks associated with perioperative care in complex foot and ankle surgery, particularly when a patient presents with multiple comorbidities that can significantly impact surgical outcomes and recovery. The need for meticulous risk assessment and tailored management is paramount to ensure patient safety and adherence to best practice standards. The best approach involves a comprehensive pre-operative assessment that meticulously identifies and quantifies all patient-specific risk factors, including the interplay between the patient’s diabetes, peripheral vascular disease, and nutritional status. This detailed evaluation allows for the development of a personalized perioperative plan that addresses each risk proactively. This includes optimizing glycemic control, implementing aggressive measures to improve vascular status and wound healing potential, and ensuring adequate nutritional support. This aligns with the ethical principles of beneficence and non-maleficence, as well as regulatory expectations for thorough patient evaluation and risk mitigation in surgical settings. It also reflects the professional duty of care to provide individualized treatment based on a complete understanding of the patient’s health profile. An incorrect approach would be to proceed with surgery without a thorough pre-operative risk assessment, assuming that standard perioperative protocols are sufficient. This fails to acknowledge the amplified risks posed by the patient’s comorbidities and could lead to preventable complications, violating the principle of non-maleficence and potentially breaching professional standards of care. Another incorrect approach would be to focus solely on the surgical procedure itself, neglecting the systemic impact of the patient’s diabetes and peripheral vascular disease on wound healing and infection risk. This narrow focus disregards the interconnectedness of physiological systems and the importance of a holistic patient assessment, which is a cornerstone of safe surgical practice. A further incorrect approach would be to delegate the entire risk assessment to junior staff without adequate senior oversight or a clear framework for identifying and managing complex comorbidities. This abdication of responsibility can lead to missed critical information and inadequate planning, undermining patient safety and the principles of supervised practice. Professionals should employ a structured, multi-disciplinary approach to risk assessment. This involves systematically gathering patient history, conducting a thorough physical examination, reviewing relevant investigations, and consulting with other specialists as needed. The decision-making process should prioritize patient safety, evidence-based practice, and clear communication with the patient regarding identified risks and the proposed management plan.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the need for thorough quality assurance and morbidity/mortality review with the potential for individual blame and the impact on team morale. The inherent complexity of surgical practice, coupled with the human element, means that errors or adverse events can occur despite best efforts. Navigating these reviews requires a commitment to systemic improvement rather than punitive measures, fostering an environment where learning from mistakes is prioritized. Correct Approach Analysis: The best approach involves a systematic, multidisciplinary review that focuses on identifying systemic factors contributing to the adverse event, rather than solely on individual performance. This includes a detailed analysis of the patient’s case, the surgical team’s actions, the pre-operative and post-operative care, and any relevant environmental or equipment factors. The goal is to understand the ‘why’ behind the event, looking for opportunities to improve protocols, training, communication, or resource allocation. This aligns with the principles of modern patient safety frameworks, which emphasize a ‘just culture’ where reporting errors is encouraged without fear of retribution, allowing for robust learning and prevention of future harm. Such a process is crucial for meeting regulatory requirements for quality improvement and patient safety, and for upholding ethical obligations to provide the highest standard of care. Incorrect Approaches Analysis: One incorrect approach would be to immediately assign blame to the lead surgeon without a comprehensive review of all contributing factors. This fails to acknowledge the complex interplay of human factors, system design, and clinical decision-making that can lead to adverse events. It can also stifle open reporting and discourage team members from participating in future reviews, undermining the entire quality assurance process and potentially violating ethical duties to foster a supportive learning environment. Another incorrect approach would be to dismiss the event as an unavoidable complication without further investigation. This neglects the core purpose of morbidity and mortality review, which is to identify potential areas for improvement, even in cases where no clear error is apparent. Overlooking such opportunities means missing chances to enhance patient safety and could be seen as a failure to meet professional standards for continuous quality improvement. A third incorrect approach would be to focus exclusively on the technical aspects of the surgery while ignoring the human factors, such as communication breakdowns, fatigue, or stress, that may have played a role. While technical proficiency is vital, human factors are significant contributors to medical errors. A review that neglects these aspects will not provide a complete understanding of the event and will therefore be less effective in implementing meaningful changes to prevent recurrence. Professional Reasoning: Professionals should approach morbidity and mortality reviews with a mindset of continuous improvement and a commitment to patient safety. The decision-making process should prioritize a systematic, data-driven investigation that considers all potential contributing factors, including human and system elements. This involves fostering an environment of psychological safety where all team members feel empowered to report concerns and participate openly in reviews. The ultimate aim is to learn from every event, whether it results in morbidity or mortality, to enhance the quality and safety of patient care.