As is often the case with scientific breakthroughs, Lister was not satisfied with prevailing explanations for high post-surgical mortality. Instead, he looked elsewhere, guided by observation. In hindsight, it is striking how long established—yet incorrect—explanations persisted. These were not only scientific but cognitive: reinforced by shared assumptions that made alternative interpretations difficult to see. In this way, prevailing theories did not simply fail to explain reality; they helped sustain it.

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Shared Responsibility in Practice

In his blog, Allred turns to a different domain—team-based care in the management of suicide risk—yet raises a parallel set of questions about how outcomes take shape. He emphasizes the shared responsibility intrinsic to high-functioning integrated care teams, characterized by a clear sense of teamship and well-designed protocols. This shared ownership can act as a protective factor: holding team members accountable, providing emotional support, reducing liability, and ultimately promoting patient safety. Transparency of workflow in primary care further strengthens these functions by making roles and processes visible.

At the same time, Allred makes clear that protocols do not operate in a vacuum. Suicide risk encounters are emotionally charged, time-constrained, and often marked by uncertainty. Under these conditions, clinical decisions are shaped not only by formal guidance but also by the clinician’s internal state. The challenge, then, is not merely to have protocols in place, but to apply them through careful reasoning rather than as reactions to emotion.

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Looking Back at Mistakes

An article by Henry Marsh, reflecting on decades as a neurosurgeon, offers a powerful lens for examining what happens when reasoning is influenced by forces outside awareness. Looking back, Marsh explores how unconscious factors shaped his decisions, blurring the line between careless mistakes and “errors of clinical judgment.” With experience, confidence can grow in ways not always matched by accuracy; repeated exposure to risk can normalize what once felt unsafe; and early impressions can anchor decisions even as new information emerges. He also notes how poor outcomes, in retrospect, can appear inevitable, obscuring the uncertainty that defined the moment of decision.

These observations extend beyond the individual clinician to the team context in which decisions unfold. Marsh describes precepting situations in which trainers deferred to senior trainees, assumptions about competence went unexamined, and responsibility was implicitly distributed across multiple people—each trusting the judgment of the others. In such moments, the team did not function as a safeguard, but as a setting in which small, individually reasonable assumptions aligned. What emerges resembles an inversion of the “Swiss cheese” model of safety: instead of multiple layers catching error, the gaps briefly line up, allowing it to pass through.

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When Conditions Align

Seen alongside Allred’s account, Marsh’s reflections clarify both the strength and vulnerability of team-based care. Allred describes structures that make shared responsibility protective—clear communication, real-time consultation, and explicit ownership of risk. Marsh, by contrast, shows what can happen when these elements are incomplete.

In the context of suicide risk, the pressures Allred describes—time constraints, emotional intensity, fragmented information, and distributed responsibility—create precisely the conditions under which the cognitive tendencies Marsh identifies are most likely to exert influence. Clinicians may rely on familiar patterns, assume a colleague has conducted a more thorough assessment, or move too quickly toward closure in order to resolve uncertainty. No single decision appears unreasonable in isolation, yet the cumulative effect can be consequential.

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Making the Invisible Visible

Across these contexts—Marsh examining the limits of individual and team-based judgment, and Allred describing the realities of clinical decision-making—the same underlying theme emerges: outcomes are shaped not only by technical skill or adherence to protocol, but by forces that are difficult to see in real time. Recognizing these influences does not diminish the value of expertise or teamwork; rather, it underscores their importance for patient safety.

Creating structured opportunities to revisit suicide risk encounters—through case reviews, team debriefs, and explicit communication loops—offers a way to surface dynamics that would otherwise remain hidden. Just as Lister transformed outcomes by questioning what could not yet be seen, teams can strengthen safety by examining how decisions are made, how responsibility is shared, and how uncertainty is communicated.

For both the saying I was reminded of and its counterpart—“the operation was a failure, but the patient survived”—the response is deliberate, intentional transparency. The foundation for building such transparency may be mutual trust and trust in the system. But I leave that for another time.

Photo by National Library of Medicine on Unsplash