Failure-to-rescue in surgical practice: a systematic review and critical appraisal of recent clinical studies

Failure to rescue (FTR)-the inability to prevent mortality following a complication-is a critical quality and safety metric reflecting a healthcare system's capacity to recognize and respond to patient deterioration. Despite its conceptual prominence, the actual use of FTR in surgical research remains poorly characterized. This systematic review addresses the gap by examining how FTR has been operationalized in recent clinical surgical studies, which subspecialties and regions contribute to the evidence base, and what bibliometric patterns reveal about knowledge uptake.

A systematic literature search was conducted following PRISMA guidelines for clinical studies on FTR published between 2019 and 2024. PubMed and PubMed Central were searched using structured queries. Studies were assessed for risk of bias using the Newcastle-Ottawa Scale. Primary outcomes were: (1) temporal trends in FTR publications, (2) FTR's use as primary or secondary outcome, and (3) its operationalization as an indicator of structure, process, or clinical outcome according to Donabedian's framework. Secondary outcomes included geographic distribution of contributing authors, surgical subspecialty representation, and bibliometric impact (Scopus and Google Scholar citations, Altmetric scores).

Of 322 articles screened, 38 met inclusion criteria. The literature consisted predominantly of multicenter retrospective studies (median sample size 29,482 patients), with FTR serving as the primary outcome in 71% of studies. FTR was most frequently operationalized to assess hospital structure (44.8%), followed by process (28.9%) and clinical outcome (26.3%). Publication output showed moderate growth from 2019 to 2021 (9-11 manuscripts/year) but declined thereafter. High-income countries dominated contributions, with the USA accounting for 47.4% of studies and Europe for 42.1%. Abdominal surgery and related subspecialties (emergency, hepatobiliary, colorectal) represented 58% of publications; emergency surgery and trauma contributed 18.4%. Despite recent publication dates, studies achieved substantial bibliometric impact: mean citations were 18.4 (Scopus) and 23.2 (Google Scholar), with 76% published in first-quartile surgical journals (mean impact factor 6.2). No significant differences in bibliometric metrics were observed across indicator categories (structure/process/outcome; p > 0.60) or surgical subspecialties (p > 0.62), suggesting a homogeneous field in terms of impact regardless of application.

Despite growing recognition of FTR as a quality metric, the volume of high-quality clinical surgical studies remains limited, geographically concentrated, and subspecialty-skewed. The field is characterized by high impact but narrow scope: predominantly retrospective North American and European studies in abdominal and emergency surgery. Standardization of FTR definitions, expansion to low- and middle-income countries, broader subspecialty engagement, and prospective interventional studies are urgently needed to advance FTR from a surveillance metric to an actionable quality-improvement tool. The field must transition FTR from a passive monitoring metric to an active driver of quality improvement to realize its potential to save lives and reduce preventable postoperative mortality.

INPLASY, identifier 202630097.