Preventing the Risk of Failure to Rescue

Executive Summary 

It’s important to quickly recognize unanticipated outcomes and initiate rescue efforts to mitigate complications for patients. Primary causes of delayed recognition of unanticipated outcomes include inadequate patient assessments and failures of communication.  

Recommended Actions  

• Accept the possibility of unanticipated outcomes and be prepared to recognize when they do occur so you can take appropriate action. 

• Take extra measures to ensure that high-risk systems are functioning smoothly. 
• Utilize efficient and clear communication strategies among providers, nurses, clinical staff and patients. 

While there is much we can do to reduce the risk of complications after procedures in medicine, it is unlikely that our complication rate will ever be zero. Thus, it is important to strive for recognition of unanticipated outcomes as quickly as possible and to initiate rescue efforts and mitigate complications for our patients. 

Atul Gawande, a professor of surgery at Harvard Medical School, discussed this issue in a commencement address published in The New Yorker¹. The address pointed out that the major differences in morbidity rates among hospitals is not in the frequency of complication rates, but rather in the success institutions have in rescuing their patients when things do not go as planned. We have noticed that the most common reason for not being able to defend a procedural complication lawsuit is due to a delay in, or inadequate, rescue efforts. 

Two recent studies have looked at the issues around postoperative care and have revealed important lessons that could help us reduce harm to our patients. One study, published by the Bulletin of the American College of Surgeons², is a retrospective review of a large claims database from a national professional liability company, which is somewhat limited in that it only identifies events that have led to lawsuits. 

Nonetheless, the study identified the primary cause of delayed recognition as inadequate patient assessment, whether it was failure to order necessary tests, failure to consider the importance of those tests or other information, or over-reliance on negative tests when patients did not improve. Second, failure of communication among providers was the cause of many delays, not only regarding the patient’s current condition, but also regarding follow-up on incidental findings that fell through the cracks. Communications must not only include covering partners, but hospitalists, nurses, primary care providers and family members as well. When postoperative patients call, office staff should be trained to contact the surgeon and not make clinical decisions independently. 

The second study appeared in the Annals of Surgery³ and was observational, following 50 surgical patients in the postoperative period, watching for process failures and other errors in their care. The study highlighted the number of non-routine events that occur in day-to-day practice that do not necessarily lead to patient harm, but that could be considered latent threats. There was an average of six non-routine events per patient, of which a median of 4.5 were considered process failures. Most (85 percent) were considered preventable and more than half were due to communication failures or individual delays in acting. 

Half of the process failures led to some form of patient harm, with many due to medication errors, management of lines and drains, and modes of pain management delivery. Inadequate patient assessment, as in the claims study, also had a higher likelihood of patient harm due to delays in rescue. 

What can we learn from these studies? First, one should understand that a procedure on a patient is never without risk. We must accept the possibility of failure, and be prepared to admit it, recognize it and take appropriate action. 

Second, due to the complexity of our medical system, process failures are very common, probably much more so than we are aware. We should be cognizant of the high-risk systems (such as management of lines and drains and of pain medication) and take extra measures to ensure that they are functioning smoothly. 

Third, we should be aware that most of these malfunctions result from communication failures among providers. We should smooth the way for input from colleagues, nurses, patients, office staff and others — and make use of that information as we continually assess our patients for progress in the postoperative period. 

There is no substitute for a careful bedside assessment of the patient who is not doing well and for careful and urgent consideration of further testing when indicated. In short, we should anticipate success, but plan for failure, to maximize the likelihood of a successful operation for our patients. 

Lessons Learned  

• Consider asking staff about factors that may be contributing to gaps in communication throughout a patient’s treatment.  
• Implement recurring training that helps staff identify malfunctions in high-risk systems.  

• Develop an efficient and reliable system for communication between providers, clinical staff and patients to avoid delays in treating unanticipated outcomes and incidental findings. 

Potential Damages 

Failures to recognize unanticipated outcomes and quickly initiate rescue efforts may result in harm to the patient. Although claims for providers who do not initiate rescue efforts in a timely and reasonable manner are relatively infrequent, providers could face negligence claims and may be required to compensate the patient for injuries sustained because of a delay. Effective communication and patient follow-ups reduce the risk of unanticipated outcomes and the need for rescue efforts.  

1 http://www.newyorker.com/online/blogs/newsdesk/2012/06/atul-gawande-failure-and-rescue.html

2 http://bulletin.facs.org/2013/06/symptoms-of-normal-recovery/

3 Annals of Surgery. 257(1):1-5, January 2013.