Failure-to-Rescue From Intraoperative Massive Hemorrhage and Preventable Deaths: A Retrospective Observational Study From Nationwide Incident Reporting System

Introduction: Intraoperative massive hemorrhage (iMH) is a rare but life-threatening surgical event associated with high mortality. Although failure-to-rescue (FTR) is widely used to evaluate surgical quality, FTR during iMH has not been well-characterized. This study aimed to describe clinical patterns of iMH and identify factors associated with FTR. Methods: We analyzed that iMH cases reported to Japan's nationwide incident reporting system from 2010 to 2023. The inclusion criteria were cases in which bleeding during noncardiac surgery required a change in surgical approach or was associated with physiological deterioration. iMH was classified into three categories based on hemorrhage controllability: category I, uncontrolled vascular injury; category II, temporarily controllable vascular injury; and category,III progressive, nonfocal bleeding. Univariable and multivariable logistic regression analyses identified factors associated with FTR. Results: A total of 353 iMH cases met inclusion criteria, and FTR occurred in 19.3% of cases. Category distribution was 27 (category I), 275 (category II), and 51 (category III), with FTR rates of 59.3%, 9.8%, and 49.0%, respectively (P < 0.001). In multivariable analysis, category II remained strongly protective (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.04–0.23), while non-daytime surgery (OR, 2.64; 95% CI, 1.23–5.67) and greater surgeon experience (per year; OR, 1.04; 95% CI, 1.00–1.08) were independently associated with higher FTR. Conclusions: FTR from iMH remains a major clinical challenge. Temporarily controllable hemorrhage showed the lowest FTR, whereas uncontrolled or progressive bleeding carried substantially higher risk. Strengthening timely escalation and intraoperative decision-making may improve rescue performance and reduce preventable deaths.