From “risk-taking surgeon” to high reliability in patient safety: proposal of a new taxonomy for surgical risk management

A recent taxonomy distinguished risky surgery, the risky surgeon, and the risk-taking surgeon, separating risk arising from the procedure from risk arising from the individual performing it. We argue that an essential dimension is missing from this taxonomy: time. Surgical risk is not a fixed property of an operation or an operator; it evolves as a surgeon accumulates experience, judgment, and technical competence. We propose that the taxonomy is better understood as a developmental trajectory than a static classification, and we distinguish two surgeons who may look identical on outcomes alone: the developmental risky surgeon, a trainee on a learning curve who recognizes limitations, seeks help, and improves with feedback, and the problematic risky surgeon, who repeats preventable errors and resists feedback. We further argue that the “risk-taking surgeon” is better understood as the risk-calibrated surgeon — an expert whose distinguishing skill is not a greater appetite for risk but a superior ability to judge which risks are worth taking. We relate this individual-level calibration to the organisational principles of high-reliability healthcare and to recent evidence on surgical never-events, unnecessary surgery, and decision support for difficult operations. We outline the practical implications of this reframing for training, supervision, assessment, and credentialing.