Scenario Analysis: This scenario is professionally challenging because it requires a surgeon to navigate the complex requirements for advanced competency assessment within a pan-European context. Misunderstanding the purpose or eligibility criteria can lead to wasted resources, delayed career progression, and potentially compromised patient care if the surgeon operates beyond their validated skill set. Careful judgment is required to ensure alignment with the established framework for advanced training and assessment. Correct Approach Analysis: The best professional practice involves a thorough understanding of the Advanced Pan-Europe Hepatopancreatobiliary Surgery Competency Assessment’s stated purpose and the specific eligibility criteria as defined by the relevant European surgical bodies and national accreditation agencies. This approach prioritizes adherence to the established regulatory framework, ensuring that the surgeon meets all prerequisites, including documented training, experience, and potentially specific procedural volumes, before applying for assessment. This aligns with the ethical imperative to practice within one’s validated competence and the regulatory requirement to meet defined standards for advanced surgical practice across Europe. Incorrect Approaches Analysis: One incorrect approach involves assuming that general surgical experience across various European countries automatically confers eligibility for advanced hepatopancreatobiliary competency assessment. This fails to recognize that the assessment is specifically designed for a specialized field and requires documented evidence of advanced training and experience within that subspecialty, often with specific pan-European recognition or alignment. Another incorrect approach is to believe that simply having a strong reputation or a high volume of general hepatobiliary cases is sufficient, without formal validation of advanced competency in the specific techniques and complex procedures covered by the assessment. This overlooks the structured nature of competency assessment, which aims to standardize and verify advanced skills beyond routine practice. A further incorrect approach is to interpret the “Pan-Europe” aspect as a mere administrative designation, believing that national-level certifications are entirely interchangeable and sufficient without considering any potential pan-European harmonization or specific requirements for cross-border recognition of advanced competencies. This disregards the collaborative efforts to establish common standards for advanced surgical training and assessment across the continent. Professional Reasoning: Professionals should adopt a proactive and diligent approach to understanding competency assessment frameworks. This involves actively seeking out official documentation from relevant European surgical associations and national regulatory bodies. A structured decision-making process would include: 1) Identifying the specific assessment in question. 2) Locating and meticulously reviewing the official purpose and eligibility criteria documents. 3) Self-assessing against each criterion, seeking clarification from official sources if any ambiguity exists. 4) Consulting with mentors or senior colleagues who have navigated similar assessment processes. 5) Documenting all relevant training, experience, and qualifications in a manner that directly addresses the assessment’s requirements.

The performance metrics show a candidate surgeon has narrowly failed to meet the required competency threshold in the Advanced Pan-Europe Hepatopancreatobiliary Surgery Competency Assessment, specifically concerning the blueprint weighting and scoring for complex biliary reconstruction techniques. This scenario is professionally challenging because it requires a delicate balance between upholding rigorous assessment standards to ensure patient safety and providing a fair and supportive pathway for a surgeon who has demonstrated significant effort and potential. The pressure to maintain the integrity of the assessment process, while also considering the individual’s progress and the potential impact on their career and future patient care, necessitates careful judgment. The best professional practice involves a thorough review of the assessment process and the candidate’s performance, followed by a structured retake policy that offers targeted remediation. This approach acknowledges the candidate’s current standing while providing a clear, actionable path for improvement. Specifically, it entails a detailed analysis of how the blueprint weighting and scoring were applied to the candidate’s performance in biliary reconstruction, identifying specific areas of weakness within that domain. Based on this analysis, a personalized remediation plan, focusing on the identified gaps, should be developed. The retake policy should then allow for a re-assessment after successful completion of this targeted remediation, ensuring that the candidate has demonstrably met the required competency in the previously weak area without compromising the overall assessment standards. This aligns with the ethical imperative to ensure surgeon competency for patient safety and the professional responsibility to support candidate development within a defined framework. An incorrect approach would be to immediately grant a pass based on overall perceived effort or potential, disregarding the specific failure in a critical area. This undermines the validity of the assessment blueprint and scoring, potentially leading to a surgeon operating with insufficient competency in a high-risk area, which is a direct violation of patient safety principles and professional standards. Another incorrect approach is to require a complete re-assessment of all modules without identifying and addressing the specific areas of deficiency. While seemingly thorough, this is inefficient and does not reflect a targeted approach to remediation. It fails to acknowledge the candidate’s strengths and places an undue burden on them, potentially discouraging further development without addressing the root cause of the failure. This deviates from best practice in competency assessment, which emphasizes identifying and rectifying specific skill deficits. Finally, an incorrect approach would be to dismiss the candidate entirely without offering a clear, structured retake opportunity after remediation. This is overly punitive and fails to consider the possibility of successful improvement with targeted support. It neglects the ethical consideration of providing a fair chance for a candidate to demonstrate mastery after addressing identified shortcomings, and it does not align with the principles of continuous professional development and assessment. Professionals should employ a decision-making framework that prioritizes patient safety above all else, while also adhering to the principles of fairness and due process for candidates. This involves: 1) objective evaluation against established assessment criteria (blueprint weighting and scoring); 2) identification of specific areas of deficiency; 3) development of targeted remediation strategies; 4) provision of a structured opportunity for re-assessment after remediation; and 5) clear communication of the process and expectations to the candidate.

The monitoring system demonstrates a significant deviation in post-operative liver function tests for a patient undergoing a complex hepatopancreatobiliary procedure. This scenario is professionally challenging due to the immediate need to interpret potentially critical patient data, balance the urgency of intervention with the need for accurate diagnosis, and ensure adherence to established clinical protocols and ethical obligations to the patient. Careful judgment is required to avoid unnecessary interventions or delays in appropriate care. The best approach involves a systematic review of the patient’s entire clinical picture, including pre-operative status, intra-operative events, and the specific nature of the surgical procedure, in conjunction with a thorough re-evaluation of the laboratory results and imaging. This includes consulting with the surgical team and relevant specialists (e.g., hepatologists, intensivists) to contextualize the abnormal liver function tests. This approach is correct because it prioritizes a comprehensive, evidence-based assessment before initiating treatment. It aligns with the ethical principle of beneficence, ensuring that any intervention is truly in the patient’s best interest and based on a sound understanding of the underlying pathology, and with professional guidelines that mandate thorough investigation of abnormal findings. An incorrect approach would be to immediately escalate to aggressive pharmacological intervention based solely on the abnormal liver function tests without a comprehensive review. This fails to consider potential transient physiological responses to surgery or other non-pathological causes for the deviation, potentially leading to iatrogenic harm and unnecessary resource utilization. Another incorrect approach is to dismiss the abnormal results as expected post-operative changes without further investigation. This neglects the professional duty to monitor patient recovery diligently and could delay the diagnosis of serious complications like ischemia, infection, or bile duct issues, violating the principle of non-maleficence. Finally, delaying consultation with specialists until a clear diagnosis is evident is also incorrect, as it prolongs the period of uncertainty and potential for adverse outcomes, failing to leverage the collective expertise available for optimal patient management. Professionals should employ a structured decision-making process that begins with recognizing and validating abnormal findings, followed by a systematic data gathering and analysis phase. This involves reviewing all available patient information, consulting relevant guidelines and literature, and engaging in interdisciplinary communication. The decision to intervene should be based on a differential diagnosis supported by evidence, always prioritizing patient safety and well-being.

This scenario presents a professional challenge due to the critical nature of operative principles, instrumentation, and energy device safety in advanced hepatopancreatobiliary surgery. The complexity of these procedures, often involving delicate structures and high-risk bleeding, necessitates meticulous attention to detail and adherence to established safety protocols. Failure in any of these areas can lead to severe patient harm, including thermal injury, unintended organ damage, or prolonged operative times, all of which carry significant ethical and regulatory implications. The surgeon must balance efficiency with patient safety, making informed decisions under pressure. The best approach involves a proactive and systematic pre-operative assessment of all energy devices and associated accessories, coupled with a clear communication protocol with the surgical team regarding their intended use and potential risks. This includes verifying the functionality of the device, ensuring appropriate settings are selected based on the surgical task, and confirming the availability of necessary safety features like return pads. This aligns with the fundamental ethical principle of non-maleficence (do no harm) and the regulatory expectation for healthcare providers to maintain competence and ensure the safe use of medical equipment. Specifically, within the European context, adherence to medical device regulations (e.g., MDR 2017/745) and professional surgical guidelines emphasizes the responsibility of the surgical team to ensure devices are used appropriately and safely to prevent adverse events. An incorrect approach would be to assume the functionality of energy devices without direct verification, relying solely on the fact that they are standard equipment. This overlooks the potential for device malfunction or improper setup, which could lead to unintended thermal spread or tissue damage, violating the principle of non-maleficence and potentially contravening medical device safety regulations. Another incorrect approach is to delegate the responsibility for energy device safety checks entirely to junior staff without direct senior surgeon oversight or confirmation. While teamwork is essential, the ultimate responsibility for patient safety rests with the lead surgeon. This abdication of responsibility could lead to critical oversights and is ethically unsound, as it fails to uphold the surgeon’s duty of care. A further incorrect approach is to proceed with the surgery without a clear understanding of the specific energy modality being used and its associated safety precautions, particularly in complex hepatopancreatobiliary anatomy. This demonstrates a lack of preparedness and a disregard for the unique risks associated with energy device application in this field, potentially leading to catastrophic complications and a breach of professional standards. The professional reasoning process should involve a structured pre-operative checklist that explicitly includes verification of all energy devices, their accessories, and safety mechanisms. This should be followed by clear intra-operative communication and continuous vigilance regarding device function and patient tissue interaction. When in doubt, the surgeon must pause, reassess, and consult with colleagues or technical support if necessary, prioritizing patient safety above all else.

This scenario presents a significant professional challenge due to the inherent complexity and time-sensitivity of managing a patient with severe hepatopancreatobiliary trauma in a critical care setting. The rapid deterioration of vital signs necessitates immediate, decisive action, yet the surgeon must balance aggressive resuscitation with the need for precise diagnostic and therapeutic interventions. The potential for catastrophic bleeding, organ damage, and subsequent multi-organ failure demands a systematic and evidence-based approach, guided by established protocols and ethical considerations. The correct approach involves a structured, multi-disciplinary resuscitation strategy that prioritizes immediate haemodynamic stabilization and haemorrhage control, followed by targeted investigations and definitive surgical management. This aligns with best practices in trauma care, emphasizing the “damage control resuscitation” philosophy. Specifically, this entails the early administration of balanced blood products (red blood cells, plasma, and platelets in a ratio often cited as 1:1:1), judicious use of crystalloids to avoid dilutional coagulopathy, and prompt surgical exploration to identify and address the source of bleeding. This approach is ethically justified by the principle of beneficence, aiming to preserve life and minimize harm by addressing the most immediate life threats first. It is also supported by established trauma guidelines, which advocate for rapid assessment, resuscitation, and intervention in severe injuries. An incorrect approach would be to delay definitive surgical exploration while continuing aggressive fluid resuscitation with crystalloids alone. This is ethically problematic as it fails to address the underlying haemorrhage, potentially leading to further haemodynamic compromise and worsening coagulopathy, thereby violating the principle of non-maleficence. It also deviates from established trauma protocols that emphasize early surgical control of bleeding in hemodynamically unstable patients with suspected intra-abdominal injury. Another incorrect approach would be to proceed directly to extensive operative repair without adequate resuscitation and haemostasis. This risks exacerbating blood loss and haemodynamic instability during a prolonged procedure, potentially leading to intraoperative death. It fails to adhere to the principles of damage control surgery, which advocate for temporizing measures in the initial phase of severe trauma to stabilize the patient before definitive reconstruction. Finally, an incorrect approach would be to focus solely on imaging studies to precisely delineate all injuries before initiating any resuscitation or surgical intervention. While accurate diagnosis is important, in a critically unstable patient, delaying life-saving measures for exhaustive imaging can be fatal. This approach prioritizes diagnostic certainty over immediate physiological support, which is ethically unacceptable when life is at immediate risk and violates the urgency dictated by established trauma algorithms. The professional decision-making process for similar situations should involve a rapid assessment of the patient’s haemodynamic status, a thorough but brief primary survey, and immediate activation of the trauma team. Based on the initial assessment, a decision must be made regarding the need for immediate operative intervention versus further resuscitation and investigation. Adherence to established trauma protocols, clear communication among the multidisciplinary team, and continuous reassessment of the patient’s response to interventions are paramount.

The audit findings indicate a potential breach of patient confidentiality and professional conduct following a complex hepatopancreatobiliary surgery. This scenario is professionally challenging because it involves balancing the immediate needs of a patient with potential long-term implications of a procedural complication, while also adhering to strict professional and ethical standards regarding patient data and communication. The surgeon is faced with a situation where a rare but serious complication has occurred, and the patient’s family is seeking information that may be sensitive and requires careful handling. The best professional approach involves immediate, transparent, and empathetic communication with the patient’s family, coupled with a thorough internal review of the complication. This includes clearly explaining the nature of the complication, its potential impact, the steps being taken to manage it, and the expected prognosis, all while respecting the patient’s privacy and dignity. This approach aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, as well as professional guidelines that mandate open communication and accountability. It also respects the patient’s right to information about their care and any adverse events. An incorrect approach would be to withhold information from the family due to fear of repercussions or to downplay the severity of the complication. This failure violates the principle of truthfulness and can erode trust between the medical team and the patient’s family. It also prevents the family from making informed decisions regarding the patient’s care and can lead to significant distress and potential legal ramifications. Another incorrect approach would be to discuss the complication and its management with colleagues in a public or informal setting without proper anonymization or a clear clinical rationale. This constitutes a breach of patient confidentiality, violating data protection regulations and professional codes of conduct that strictly prohibit the unauthorized disclosure of patient information. Such actions can lead to severe disciplinary measures and damage the reputation of the healthcare institution. Finally, an incorrect approach would be to delegate the entire communication and management of the complication to a junior member of the surgical team without adequate supervision or support. While teamwork is essential, the primary responsibility for communicating serious complications and their management ultimately rests with the senior surgeon. Failing to provide direct oversight and leadership in such critical situations can lead to miscommunication, inadequate care, and a failure to uphold professional accountability. Professionals should approach such situations by first ensuring the patient’s immediate safety and stability. Then, they should initiate a structured communication plan, involving relevant team members, to prepare for a transparent and empathetic discussion with the family. This process should include a thorough review of the event, identification of lessons learned, and adherence to all institutional policies and professional ethical guidelines regarding patient care and data privacy.

Scenario Analysis: This scenario presents a professional challenge rooted in the ethical obligation of honesty and transparency versus the potential for perceived personal gain or professional advancement. The candidate is aware of a significant resource gap that could impact their preparation for a high-stakes assessment. Navigating this requires careful judgment to uphold professional integrity while seeking appropriate support. The core tension lies in how to disclose this information and what actions to take, balancing personal responsibility with the need for institutional support. Correct Approach Analysis: The best professional practice involves proactively and transparently communicating the identified resource limitations to the relevant training program coordinator or designated faculty member. This approach involves clearly articulating the specific deficiencies in preparation resources and the potential impact on the candidate’s readiness for the Advanced Pan-Europe Hepatopancreatobiliary Surgery Competency Assessment. By doing so, the candidate initiates a dialogue that allows for collaborative problem-solving. This is ethically sound as it upholds the principle of honesty and avoids any misrepresentation of preparedness. It also aligns with professional guidelines that encourage open communication within training programs to ensure the highest standards of patient care and professional development. This proactive disclosure allows the program to potentially allocate additional resources, provide alternative learning materials, or adjust timelines if deemed necessary, thereby ensuring the candidate receives adequate preparation without compromising the assessment’s integrity. Incorrect Approaches Analysis: One incorrect approach is to proceed with the assessment without disclosing the resource limitations, hoping that existing knowledge and limited resources will suffice. This is ethically problematic as it risks misrepresenting one’s level of preparedness and could lead to a suboptimal performance, potentially impacting patient safety if the assessment is directly linked to clinical practice. It violates the principle of honesty and could be seen as a failure to take full responsibility for one’s professional development. Another incorrect approach is to seek external, unapproved resources or to engage in practices that could be construed as circumventing the established assessment preparation framework. This is ethically unsound as it undermines the integrity of the assessment process and could violate institutional policies or professional conduct guidelines. It also fails to leverage the structured support and oversight that the training program is designed to provide. A further incorrect approach involves delaying the disclosure until immediately before the assessment or after its completion. This is professionally irresponsible as it deprives the training program of the opportunity to provide timely support and address the resource gap effectively. It can also create an impression of a lack of foresight or a reluctance to engage constructively with the program’s structure. Professional Reasoning: Professionals facing similar situations should adopt a framework that prioritizes transparency, integrity, and collaborative problem-solving. This involves: 1. Self-assessment: Honestly evaluate personal preparedness and identify specific areas of concern. 2. Information gathering: Understand the available resources and any identified deficiencies. 3. Proactive communication: Engage with the appropriate program leadership or faculty to discuss concerns openly and honestly. 4. Collaborative solution-finding: Work with the program to explore potential solutions, whether it involves additional resources, alternative learning strategies, or timeline adjustments. 5. Adherence to guidelines: Ensure all actions taken are in compliance with institutional policies and professional ethical codes. This systematic approach ensures that professional development is supported ethically and effectively.

This scenario presents a significant ethical and professional challenge due to the inherent conflict between a surgeon’s duty to provide optimal care and the patient’s right to informed consent, particularly when dealing with complex anatomy and potential for unexpected findings. The surgeon must navigate the delicate balance of preparing the patient for likely scenarios while respecting their autonomy and avoiding undue alarm or over-promising. The core of the challenge lies in accurately conveying the probabilistic nature of surgical findings and the subsequent management decisions without compromising the patient’s understanding or trust. The best approach involves a comprehensive and transparent discussion with the patient and their family, focusing on the most probable anatomical variations and their implications for the surgical plan. This includes clearly outlining the standard procedure, detailing the specific anatomical considerations relevant to the patient’s condition (e.g., potential for aberrant vasculature, unusual ductal anatomy), and explaining how these variations might necessitate modifications to the surgical approach or even a change in the operative procedure. Crucially, this discussion must emphasize that these are potential scenarios, not certainties, and that decisions will be made intraoperatively based on direct visualization and the patient’s best interests. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and autonomy (respecting the patient’s right to make informed decisions), as well as professional guidelines that mandate thorough preoperative assessment and patient education. The European Union’s General Data Protection Regulation (GDPR) indirectly supports this by emphasizing the need for clear communication and consent regarding personal health data and treatment, which includes understanding the potential risks and benefits of a procedure. Furthermore, professional surgical bodies across Europe advocate for shared decision-making, ensuring patients are active participants in their care. An approach that focuses solely on the most common anatomical presentation without adequately discussing potential deviations risks failing to obtain truly informed consent. If unexpected anatomy is encountered and the surgeon proceeds with a plan not previously discussed, it could be perceived as a deviation from the agreed-upon care, potentially leading to patient dissatisfaction or even legal challenges. This would violate the principle of autonomy and potentially breach the duty of care by not adequately preparing the patient for all reasonably foreseeable outcomes. Another unacceptable approach would be to present a worst-case scenario as the most likely outcome. This could cause undue anxiety and distress for the patient, potentially leading them to refuse necessary treatment or to make decisions based on fear rather than a balanced understanding of their condition. Such an approach would contraindicate the principle of non-maleficence (do no harm) by causing psychological distress. Finally, deferring all discussion of anatomical variations to the intraoperative period, with minimal preoperative explanation, is professionally unsound. While intraoperative decisions are often necessary, a lack of prior discussion about potential challenges leaves the patient unprepared and undermines the foundation of informed consent. This fails to uphold the surgeon’s responsibility to educate and empower the patient. Professional decision-making in such situations requires a structured approach: first, a thorough review of the patient’s imaging and relevant literature to anticipate potential anatomical complexities; second, a clear, empathetic, and honest conversation with the patient and their family, using understandable language to explain probabilities and potential management strategies; third, documenting the discussion and the patient’s understanding; and fourth, maintaining flexibility and readiness to adapt the surgical plan intraoperatively while always prioritizing the patient’s safety and well-being.

The analysis reveals a scenario where a surgeon is faced with a complex hepatopancreatobiliary (HPB) case requiring a high-risk procedure. The professional challenge lies in balancing the imperative to provide optimal patient care with the ethical and professional obligation to ensure patient safety and informed consent, especially when the planned approach carries significant inherent risks. This situation demands meticulous structured operative planning and robust risk mitigation strategies, moving beyond a purely technical surgical focus to encompass comprehensive patient management and ethical considerations. The best approach involves a thorough, multi-disciplinary pre-operative assessment and detailed discussion with the patient. This includes a comprehensive review of imaging, pathology, and patient comorbidities to refine the surgical plan. Crucially, it necessitates a transparent and in-depth discussion with the patient and their family about the specific risks, potential complications, expected outcomes, and alternative treatment options, ensuring they can provide truly informed consent. This aligns with the ethical principles of beneficence, non-maleficence, and patient autonomy, as well as professional guidelines emphasizing shared decision-making and comprehensive pre-operative evaluation. The structured planning extends to developing contingency plans for anticipated complications and ensuring the availability of necessary resources and expertise. An approach that prioritizes proceeding with the surgery based on the surgeon’s experience alone, without a detailed, documented, multi-disciplinary review and explicit patient discussion of all risks, fails to uphold the principle of non-maleficence. It bypasses the crucial step of ensuring the patient fully understands the potential for harm and the rationale behind the chosen, potentially high-risk, intervention. This also neglects the ethical imperative of patient autonomy, as informed consent cannot be truly given without complete disclosure. Another unacceptable approach would be to postpone the surgery indefinitely due to perceived high risk without exploring all avenues for risk mitigation or discussing alternative management strategies with the patient. While caution is important, an indefinite delay without a clear plan for re-evaluation or alternative treatment can be detrimental to the patient’s well-being and may not align with the principle of beneficence, especially if the condition is progressive. Finally, an approach that involves proceeding with a less invasive but potentially suboptimal procedure without a thorough discussion of its limitations and the potential benefits of the higher-risk, more definitive surgery would also be professionally deficient. This could lead to suboptimal patient outcomes and may not fully respect the patient’s right to choose the treatment that best aligns with their goals, even if it involves higher immediate risks. Professionals should adopt a decision-making process that begins with a comprehensive understanding of the clinical problem and the patient’s overall health. This is followed by rigorous, multi-disciplinary planning, focusing on identifying and mitigating all potential risks. The cornerstone of this process is open, honest, and detailed communication with the patient, ensuring they are an active participant in the decision-making, leading to truly informed consent. This framework prioritizes patient safety, ethical conduct, and optimal clinical outcomes.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate need to improve patient outcomes with the established processes for quality assurance and learning from adverse events. The pressure to act quickly after a significant morbidity event can lead to hasty decisions that may not fully address the root causes or comply with established protocols. Careful judgment is required to ensure that the response is both effective and procedurally sound, adhering to the principles of continuous quality improvement and patient safety mandated by European healthcare regulations and professional guidelines. Correct Approach Analysis: The best professional practice involves a structured, multidisciplinary morbidity and mortality (M&M) review that systematically analyzes the case. This approach prioritizes identifying all contributing factors, including system-level issues and human factors, through a non-punitive, open discussion. The review should then lead to the development of specific, actionable recommendations for process optimization, which are then integrated into the hospital’s quality assurance program and disseminated for broader learning. This aligns with the European framework for healthcare quality and patient safety, which emphasizes systematic review of adverse events to drive improvement and prevent recurrence, fostering a culture of safety and accountability without blame. Incorrect Approaches Analysis: One incorrect approach involves immediately implementing a new surgical technique based on the perceived failure of the previous one without a thorough M&M review. This bypasses the essential process of understanding the root causes of the morbidity, potentially leading to the adoption of a new technique that may have its own risks or fail to address the underlying systemic issues. This violates the principles of evidence-based practice and systematic quality improvement mandated by European healthcare standards. Another incorrect approach is to focus solely on individual surgeon error and implement punitive measures. This approach is counterproductive to fostering a culture of safety and learning. European guidelines on patient safety and quality assurance strongly advocate for a non-punitive approach to M&M reviews, focusing on system improvements rather than individual blame. Such an approach discourages open reporting and learning from mistakes, ultimately hindering progress in patient care. A third incorrect approach is to delay the M&M review until all other patient care responsibilities are met. While workload is a reality, significant morbidity events require prompt and thorough investigation. Postponing the review can lead to a loss of critical details, a diminished sense of urgency, and a failure to implement timely corrective actions, thereby compromising patient safety and contravening the proactive quality assurance expectations within European healthcare systems. Professional Reasoning: Professionals should approach such situations by prioritizing the established quality assurance framework. This involves recognizing the M&M review as a critical, non-negotiable step in the process of learning from adverse events. Decision-making should be guided by the principles of patient safety, continuous improvement, and adherence to regulatory requirements for quality management in healthcare. The focus should always be on understanding the ‘why’ behind the event through a systematic, multidisciplinary lens, leading to evidence-based interventions that enhance patient care and system resilience.