Failure to Rescue in Surgery: When Systems Fail and Surgeons’ Traits Matter – A Qualitative Study

Background Complications are inherent to surgery and can unfortunately lead to loss of patients. Death following a potentially manageable complication is referred to as failure to rescue (FTR) and is used as a surgical quality metric. But beyond its metric function, FTR is a traumatic event for patients, families and surgical teams. Despite its high stakes and emotional weight, FTR is rarely discussed, limiting opportunities for learning, support, and curriculum development. Aims To explore how surgeons make sense of FTR and derive implications for surgical education and culture. Methods Using a constructivist grounded theory approach and convenience sampling, we conducted semi-structured interviews with practicing or recently retired surgeons with a minimum of 5 years of experience in their senior years. Interviews were audio-recorded, transcribed verbatim, and iteratively coded using software-assisted analysis, constant comparison, and progressive categorization; recruitment continued until thematic sufficiency. Results Fourteen surgeons were interviewed, including 12 men (86%) and 2 women (14%), aged 34 to 68 years. Specialties included abdominal surgery (64%), orthopedics/traumatology (29%), and vascular surgery (7%). Five themes were developed: (1) Trapped in a flawed system: Surgeons perceived FTR as inevitable within systemic and institutional constraints; (2) Hierarchical barriers continue to predominate, hindering adequate reaction and shared decision-making; (3) Imperfect heroes: Surgeons saw themselves as passionate, resilient, and driven, yet vulnerable to narcissism, horizontal violence, and performative behaviors; (4) Coping with failure: FTR events were painful yet contributed to improved clinical expertise; and (5) Strategies and Tools for Rescue, characterized by sharing personal strategies and proposing system-level improvements. Conclusion FTR emerged as a profound “surgeon experience” that shapes individual emotional well-being and professional development. Traits valued in surgery were described as potentially delaying escalation and help-seeking approaches. Educational and cultural efforts that foster humility, reduce hierarchical barriers, and strengthen peer support may shift FTR from a tragedy toward collective learning.