This commentary discusses the role of the Scottish Audit of Surgical Mortality (SASM) on trends in adverse events and related processes in care. The authors describe operational aspects of SASM and report on nearly 45,000 deaths reviewed in the past decade. Findings include a decrease over time in the percentage of deaths for which adverse events in management either caused or contributed to the outcome. The authors conclude that voluntary mortality audits may lead to important changes in practice and focusing on adverse events within the process of care serves as an equally important outcome in using such a system. If successfully identified, both individual physicians and their institutions should be held accountable in designing targeted improvements.