The transparent compilation and handling of complications entails two very important aspects.

One relates to the patients’ perspective: It is probably not the responsible surgeon who alone should evaluate whether an outcome or complication is acceptable. The patient and responsible surgeon should agree on the expected outcomes and risks – and evaluate whether they are “acceptable� within this frame of reference.

The second aspect is even more important. Philosophically, the unexpected is always a possibility, unless one has perfect knowledge of how the universe works. Science aims to describe theories to explain the causality of events, but the theories can only be viewed as approximations of reality; approximations that need to be adjusted when prognoses based on commonly accepted knowledge fail to predict the future. The philosopher coined the term “black swans� to describe unexpected events or observations that falsified an accepted belief. Unfortunately, such events can occur even if we, as surgeons and scientists, act conscientiously within accepted theoretical paradigms and we honest intent to help our patients. In this event, a complication is something that shows that our action was based on incomplete or faulty knowledge. Naturally, dissemination of such observations of “black swans� can only benefit our specialty. The discordant data require better theories and practice and the knowledge of a possible untoward event will serve as a warning to others not to repeat a mistake.

The handling of complications is one of the most important issues in our professionalism. We need to provide our services in dialogue with our patients and we need to exert professional ethics and self-regulation to prevent complications that arise from professional negligence or ignorance. We also need to exert professionalism to learn from the complications that are “black swans� and to prepare collegially to handle the unexpected.

I am convinced that transparency with our practice and outcomes will be an important future means of improving professional performance and knowledge. I salute the congress, the participants and organizers and wish you success in the important endeavor of professional perfection.

The human factor frequently appears as an immediate cause of adverse events (4). Prior to 1990, the cultural approach in risk management was geared towards finding the responsibilities of the authors of errors. From 1990, J. Reason (4) develops a new approach to the risk by considering that human error is inevitable but "Although we can not change the human condition, we can change the conditions in which humans work ... Human errors are perceived as consequences rather than causes. "

Human errors develop in a context (root causes) favoring their occurrence. L. Leape (5) states that "Human error is not avoidable but it is relatively predictable. If the magnitude of the medical error is enormous, it is because of the use of poorly designed systems and not the irresponsibility of staff. " D. Berwick (6) reinforces this systemic approach to risk by demonstrating that only 2-3% of clinical errors are due to incompetence, carelessness, sabotage or negligence, revealing that 97-98% of clinical errors are due to the health system hazards.

Recognized protocols are used in care systems to investigate and analyze incidents (Clinical Safety Research Unit (Imperial College London), Association of Litigation and Risk Management (ALARM), from the identification of the causes of an event (7,8) The Human Factors Analysis and Classification System (HFACS) was originally proposed for US Navy aviation and then modified to apply to a wide variety of other risks, including those related to care, to study and analyze the human contribution to accidents and incidents. It takes into account individual, environmental, governance and organizational factors. For example: action or omission in the care process, slip of the tongue, misjudgment, forgetfulness, unsafe gesture, improper or incomplete implementation of a procedure, deliberate failure to practice safe practices, procedures or standards, search for root causes, contributing factors to the occurrence of these errors to correct them by installing defenses or barriers, to create a safer environment. In this context, at the individual level, the most frequent contributions were errors in judgment, inadequate risk assessment or lack of critical reflection. Communication and coordination, mainly due to inadequate or ineffective communication, have been often implicated. Half of the reports have blamed complex interactions in a sociotechnical environment. These methodologies are useful. Exploited carefully, they must guide our mitigation and response strategies better than simple assumptions and opinions.

The meeting in Bombay is the opportunity to create a database that could be used in the neurosurgical career development by creating a specific training module for managing risks and complications.

This teaching that we should organized must be focused to the practical implementation and the study of scenarios, thanks to workshops in small groups, exercises in simulation based on real scenarios. To create this bank of scenarios close to the field, teams of experts must be involved: neuro-traumatology, cerebrovascular, tumors, spine, functional neurosurgery, neuropediatrics, peripheral nerves, ... A syllabus of skills - knowledge, know-how and skills - taking into account the aspect of the mastery of illness is essential, but a critical analysis of the environment will optimize access to neurosurgical clinical performance.

The change of practice and culture goes through initial training.

1- Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Institute of Medicine. Washington (DC) 1999.

2- DRESS ; Les événements indésirables graves liés aux soins observés dans les établissements de santé : premiers résultats d’une étude nationale. https://drees.solidarites-sante.gouv.fr/IMG/pdf/er398-3.pdf

3- Rolston JD, Han SJ, Lau CY, Berger MS, Parsa AT: Frequency and predictors of complications in neurological surgery: National trends from 2006 to 2011. J Neurosurg 2014; 120:736–45

4- Reason J. “Human error: models and management�, BMJ, vol. 320, n° 7237, 18 mars 2000, p. 768-770.

5- Dr Lucien Leape https://www.npsf.org/page/lucianleapemd

6- Berwick DM. The Institute for Healthcare Improvement. Committee on Senate Appropriations Subcommittee of Labor, Health and Human Services, March 13, 2003

7- Vincent C. Systems analysis of clinical incidents – The London Protocol https://www.imperial.ac.uk/patient-safety-translational-research-centre/education/training-materials-for-use-in-research-and-clinical-practice/the-london-protocol/

8- Vincent C. How to investigate and analyse clinical incidents. BMJ 2000;320:777-781