Evolution of trends in risk management.

In the past, the detection and response to adverse clinical events were viewed as an inherent part of professionalism; and, if perceived problems were not sorted out at that level, the ultimate expression of dissatisfaction was litigation. There are now demands for the adoption of more transparent and effective processes for risk management. Reviews of surgical practice have highlighted the presence of unacceptable levels of avoidable adverse events. This is being resolved in two ways. First, attention is being directed to the extent that training and experience have on outcomes after surgery, and both appear to be important. Second, a greater appreciation of human factors engineering has promoted a greater involvement of surgeons in processes involving teamwork and non-technical skills. The community wants surgeons who are competent and health-care systems that minimize risk. In recent times attention has been focused on the turmoil associated with change; but, when events are viewed over a period of several decades, there has been considerable progress towards these ideals. Further advancement would be aided by removing the adversarial nature of malpractice systems that have failed to maintain standards.