Between-Hospital Variation in Failure to Rescue After Major Surgery

Failure to rescue (FTR), defined as postoperative mortality among patients with treatable complications, is a recognized patient safety concern. FTR reflects institutional capacity for timely management of deterioration and has been proposed as a quality indicator less dependent on baseline complication risk. Evidence on systematic hospital-level variation outside the US remains limited.

To estimate national postoperative FTR rates, quantify between-hospital variation, and identify hospitals with better- or worse-than-expected performance using risk-standardized mortality ratios (RSMRs).

This retrospective cohort study conducted in Switzerland applied the Agency for Healthcare Research and Quality (AHRQ) patient safety indicator 04 (PSI04) definition to administrative hospital data to all acute-care hospitals in Switzerland from January 2019 to December 2023. Participants included surgical inpatients with at least 1 PSI04-defined complication (ie, deep vein thrombosis and/or pulmonary embolism, pneumonia, sepsis, shock and/or cardiac arrest, and gastrointestinal hemorrhage and/or ulcer). Hospital-level variation was assessed using multilevel logistic regression with hospital random intercepts and summarized with RSMRs. Alternative models were estimated to explore the stability of results.

Acute care hospitalization.

In-hospital mortality following eligible complications, expressed as crude FTR rates and RSMRs. The intraclass correlation coefficient quantified systematic performance variation.

Among 41 506 inpatients undergoing surgery with PSI04-defined complications (mean [SD] age, 67.6 [14.8] years; 24 692 [59.5%] men), 7310 in-hospital deaths occurred. The crude national FTR rate was 18.07 (95% CI, 17.66-18.50) of 100 admissions. In 61 hospitals with at least 100 cases, adjusted odds ratio for death varied between the lowest- and highest-performing hospitals from 0.56 (95% CI, 0.38-0.80) to 1.75 (95% CI, 1.59-1.92). Hospital-level variance was 0.114 (intraclass correlation coefficient, 0.034; 95% CI, 0.020-0.055). An estimated 1045 of 7114 observed FTR deaths (14.7%) within the hospital sample were attributable to below-average hospital performance. Five hospitals (8.2%) performed significantly better than expected, 42 (68.9%) as expected, and 14 (23.0%) substantially worse than expected based on RSMR 95% CIs. Poorer performance clustered in medium- and high-volume hospitals. Alternative regression models confirmed stability of results.

In this cross-sectional study of FTR, nearly 1 in 5 patients undergoing surgery who experienced serious complications died, with substantial between-hospital variation. Multilevel modeling indicated that institutional performance accounted for 1045 potentially avoidable deaths. These findings support FTR as an international patient safety indicator and highlight the need to investigate organizational determinants of variation to inform system-level improvement strategies.