The Critical Gap in Surgical Safety: Why Failure to Rescue Matters
In the landscape of modern perioperative medicine, the focus has traditionally centered on minimizing the incidence of postoperative complications. While reducing the frequency of adverse events—such as infections, hemorrhages, or respiratory failure—remains a pillar of surgical quality, a more nuanced metric has emerged as a primary indicator of hospital performance: Failure to Rescue (FTR). FTR is defined as the inability of a healthcare system to prevent death in a patient who has developed a treatable, major complication.
Unlike traditional mortality rates, which are often heavily influenced by a patient’s baseline health and the complexity of the surgical procedure, FTR focuses specifically on the hospital’s response to deterioration. It asks a fundamental question: Once a complication occurs, does the institution have the systems in place to recognize it and intervene effectively? A recent comprehensive study published in JAMA Network Open by Schwappach and colleagues provides a stark look at how these systems vary across a national healthcare landscape, specifically within the Swiss hospital system.
Understanding the Failure to Rescue Paradigm
Failure to Rescue has gained international recognition because it separates the ‘occurrence’ of a complication from the ‘outcome’ of that complication. In a high-performing hospital, a patient may still develop pneumonia or a pulmonary embolism, but the institution’s rapid response teams, intensive care capacity, and vigilant nursing staff ensure the patient survives. In contrast, a lower-performing hospital may have similar complication rates but significantly higher mortality because the deterioration is caught too late or managed inadequately.
This study, titled ‘Between-Hospital Variation in Failure to Rescue After Major Surgery,’ represents a significant step forward in understanding the organizational determinants of surgical safety outside the United States, where much of the original FTR research was conducted. By applying standardized metrics to a national cohort, the researchers have quantified the impact of institutional performance on patient survival.
Study Design and Methodology: The Swiss National Cohort
This retrospective cohort study utilized administrative data from all acute-care hospitals in Switzerland, spanning a five-year period from January 2019 to December 2023. The researchers focused on surgical inpatients who experienced at least one major complication as defined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 04 (PSI04).
The PSI04 definition is specifically designed to capture ‘treatable’ complications, including:
1. Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
2. Pneumonia
3. Sepsis
4. Shock and/or Cardiac Arrest
5. Gastrointestinal Hemorrhage and/or Ulcer
The final analysis included 41,506 patients who underwent major surgery and subsequently developed one or more of these complications. To ensure statistical robustness, the study focused on 61 hospitals that handled at least 100 cases of such complications during the study period. The researchers employed multilevel logistic regression with hospital random intercepts to calculate Risk-Standardized Mortality Ratios (RSMRs), allowing for a fair comparison between institutions with different patient demographics.
Key Findings: A High Burden of Postoperative Mortality
The results of the study are both illuminating and concerning for the surgical community. Among the 41,506 patients who experienced a PSI04-defined complication, there were 7,310 in-hospital deaths. This resulted in a crude national FTR rate of 18.07 per 100 admissions (95% CI, 17.66-18.50). In simpler terms, nearly one in five surgical patients who suffered a major, treatable complication did not survive their hospital stay.
Perhaps the most significant finding was the degree of variation between hospitals. Even after adjusting for patient age, sex, and comorbidities, the odds of death varied dramatically depending on where the patient was treated. The adjusted odds ratio (OR) for death ranged from 0.56 (95% CI, 0.38-0.80) in the highest-performing hospitals to 1.75 (95% CI, 1.59-1.92) in the lowest-performing ones.
The ‘Avoidable Death’ Metric: 1,045 Lives at Stake
One of the most impactful statistics generated by this study is the number of ‘attributable’ deaths. By comparing actual mortality to the mortality that would be expected if all hospitals performed at the national average, the researchers estimated that 1,045 deaths—representing 14.7% of all FTR deaths in the sample—were attributable to below-average hospital performance.
This suggests that if the lower-performing hospitals were able to elevate their ‘rescue’ systems to match the national average, over a thousand lives could have been saved over the five-year period. This highlights FTR not just as a statistical metric, but as a critical target for health policy and quality improvement initiatives.
The Volume Paradox: Why Bigger Isn’t Always Better
Historically, higher surgical volume has been associated with better outcomes—a concept known as the ‘practice makes perfect’ effect. However, the Swiss data presented a more complex picture. The study found that poorer performance in FTR was actually clustered among medium- and high-volume hospitals.
While high-volume centers often have more advanced technology and specialized staff, they may also face challenges related to communication, overcrowding, and the dilution of nursing care across a larger patient base. This finding suggests that volume alone is not a guarantee of safety. Instead, the ‘organizational DNA’—the culture of safety, the ratio of nurses to patients, and the efficiency of escalation protocols—appears to be the primary driver of successful rescue.
Clinical and Organizational Implications: The ‘Surveillance and Rescue’ Chain
To improve FTR rates, clinicians and hospital administrators must view the process of ‘rescue’ as a chain of events that begins long before a patient arrests. This chain involves:
1. Vigilant Surveillance
This is primarily the domain of nursing staff. High nurse-to-patient ratios are consistently linked to lower FTR because they allow for the detection of subtle changes in vital signs, mental status, or urine output before a crisis occurs.
2. Timely Escalation
A hospital must have a culture where junior staff feel empowered to voice concerns. Barriers to escalation, such as rigid hierarchies or fear of ‘bothering’ a surgeon, can lead to fatal delays.
3. Rapid Response Systems
Once a complication is recognized, the institution must have the capacity to deploy advanced care—such as ICU consultation, interventional radiology, or emergency re-operation—immediately.
4. Effective Management
The final step is the high-quality clinical management of the complication itself, following evidence-based protocols for sepsis, shock, or hemorrhage.
Expert Commentary: Moving Beyond Risk Adjustment
The study by Schwappach and colleagues underscores that while we cannot always prevent complications, we can and must improve how we respond to them. The fact that 23% of the studied hospitals performed significantly worse than expected suggests a systemic issue that requires more than just individual clinician effort; it requires institutional reform.
One limitation of the study, common to administrative data analyses, is the potential for coding variations between hospitals. However, the use of the AHRQ PSI04 framework and the stability of the results across alternative regression models provide strong evidence for the validity of these findings. Furthermore, the Swiss context provides a unique perspective on a high-resource healthcare system that still exhibits significant gaps in performance, suggesting that financial resources alone are not the solution to FTR.
Conclusion: FTR as a Global Imperative for Patient Safety
In conclusion, this cross-sectional study confirms that Failure to Rescue is a potent and necessary quality indicator for surgical care. The finding that nearly 15% of postoperative deaths in patients with complications were attributable to hospital-level variation serves as a call to action for healthcare leaders.
Improving surgical safety in the coming decade will likely depend less on developing new surgical techniques and more on perfecting the organizational systems that catch and correct deterioration. By standardizing the ‘rescue’ process and addressing the organizational determinants of variation, hospitals can bridge the gap between a major complication and a successful recovery.
References
1. Schwappach D, Zwahlen M, Havranek MM. Between-Hospital Variation in Failure to Rescue After Major Surgery. JAMA Netw Open. 2026;9(2):e2555855. doi:10.1001/jamanetworkopen.2025.55855.
2. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-1375.
3. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of failure-to-rescue. Med Care. 1992;30(7):615-629.
4. Sheetz KH, Ghaferi AA, Nathan H, et al. Failure to Rescue After Major Surgery: A New Framework for Quality Improvement. Annals of Surgery. 2016;264(3):416-422.
