Failure-to-rescue events may be shaped by both health care system constraints and surgical culture, according to a qualitative study published in JAMA Network Open in which surgeons described hierarchy, self-reliance, and communication barriers as factors that could affect recognition of and response to complications.
Failure to rescue (FTR), defined as death following a potentially manageable complication, is widely used as a surgical quality metric reflecting surveillance, timely escalation, and institutional rescue capacity. Researchers conducted semistructured interviews with 14 board-certified surgeons in Switzerland and Austria. Eligible participants had at least 5 years of surgical experience or were recently retired; nearly all participants described personal experience with FTR events.
Participants represented abdominal surgery, orthopedics or traumatology, and vascular surgery. Using a constructivist grounded theory approach, the researchers analyzed interview transcripts to identify themes related to rescue failures, coping, and learning. Interviews were conducted in German from February to May 2023, and data analysis was performed from February 2024 to April 2025.
Researchers identified 5 themes: being trapped in a flawed system, hierarchical barriers to escalation, being imperfect heroes, coping through failure, and strategies and tools for rescue. Participants frequently described FTR as arising from the interplay of organizational conditions and professional norms that influenced communication, escalation, and decision-making.
System-level barriers were a recurring theme. Participants described fragmented care associated with multiple handoffs, administrative demands that reduced time with patients, fatigue and prolonged shifts, communication failures between clinical teams, and delays in access to operating rooms. Several surgeons also raised concerns about complex surgical cases being managed at lower-volume hospitals and about economic pressures influencing care delivery. As context, the researchers cited a Swiss study that reported a 3.1-fold difference in adjusted odds of death across hospitals among 41,506 surgical patients, underscoring the potential importance of institutional rescue performance.
Hierarchical barriers also emerged as a major theme. Participants described situations in which junior physicians or other team members were reluctant to challenge senior clinicians or escalate concerns. Some surgeons recalled instances in which concerns were voiced but not acted on, while others described decision-making authority becoming concentrated in the most senior physician present. The researchers noted that experienced and senior surgeons were also described as vulnerable to pride, reluctance to seek support, and difficulty abandoning an initial plan.
Professional identity was another prominent theme. Participants characterized surgeons as highly confident, resilient, and action-oriented, but they also described circumstances in which those same traits could become obstacles. In the "imperfect heroes" theme, the researchers described a paradox of surgical culture: confidence and decisiveness may enable lifesaving action, but self-reliance that is not well calibrated to the situation may delay consultation, make criticism harder to accept, and impede recognition of personal limitations.
Participants also described emotional consequences following FTR. Feelings of guilt, shame, and isolation were commonly reported, and many surgeons said reflection on these events often occurred privately rather than through formal support mechanisms. The researchers linked these findings to the second victim phenomenon, in which clinicians experience distress following adverse events. Some participants also described avoidant coping strategies, including withdrawal and alcohol use.
At the same time, participants frequently described adverse events as important learning experiences that influenced future clinical practice. The researchers discussed these findings in the context of Bosk's Forgive and Remember framework, which distinguishes technical and judgment errors from perceived failures of professional conduct. The framework helps explain why some surgical errors may be treated as teachable, whereas others may reinforce blame or silence, limiting opportunities to learn from FTR events.
When discussing approaches that might reduce rescue failures, participants emphasized preparation, standardized clinical pathways, earlier consultation with colleagues, and organizational cultures that encourage help-seeking. Surgeons also highlighted the potential value of centralizing complex surgical care and maintaining structured forums for discussing complications, particularly when those settings support learning rather than blame. Some participants described UK and US learning environments as more accepting of questions without judgment, a contrast they drew with their own settings.
The findings should be interpreted in light of several limitations. The study included 14 volunteer surgeons, which may have favored participants who were more willing to discuss adverse events. Most participants were men, and nearly all practiced in Switzerland. The study did not include hospital-level FTR rates, so researchers could not assess whether surgeons' responses were influenced by the rescue performance of their own institutions. The surgeon-centered design also did not capture the perspectives of nurses or other frontline staff involved in monitoring and escalation.
The qualitative design was intended to explore experiences and perceptions and cannot establish causal relationships or determine how frequently the identified factors contribute to FTR events. The researchers also noted that AI-assisted transcription may have introduced residual errors despite human review and that translated quotations may contain minor language inconsistencies.
Overall, the study suggests that surgeons perceive rescue failures as arising from an interplay between organizational conditions and professional culture. "We were perhaps too proud to call someone in," a senior surgeon recalled while reflecting on a specific case, according to Hélène L. Gros, MD, of Clarunis University Digestive Health Care Centre Basel, and colleagues. Dr Gros and Victoria Werdecker, MD, contributed equally to the study.
The authors declared no competing interests.
Source: JAMA Network Open
