General Surgery Board Review Risk Assessment & Management 5 — Questions and Answers
Question 1: Which of the following best describes the 'failure to rescue' metric as used in surgical quality improvement?
- The rate of preventable surgical complications
- The rate of death following a major postoperative complication (Correct answer)
- The number of unplanned returns to the operating room
- The rate of ICU readmission within 30 days
Correct answer: The rate of death following a major postoperative complication
Failure to rescue measures the rate of death after a major complication, reflecting the system's ability to detect and respond to complications rather than the complication rate itself.
Question 2: A 52-year-old woman with obstructive sleep apnea (OSA) is scheduled for elective laparoscopic Roux-en-Y gastric bypass. Which perioperative risk specifically attributable to OSA should be discussed?
- Increased risk of intraoperative anesthetic awareness
- Increased risk of postoperative respiratory failure and airway obstruction (Correct answer)
- Elevated risk of intraoperative bronchospasm
- Higher incidence of postoperative delirium
Correct answer: Increased risk of postoperative respiratory failure and airway obstruction
OSA significantly increases risk of postoperative upper airway obstruction and respiratory failure, especially with opioid analgesia and residual anesthetic effects causing further pharyngeal muscle relaxation.
Question 3: The Caprini score is used to risk-stratify patients for perioperative VTE. Which patient scenario would score highest?
- 40-year-old woman undergoing appendectomy with no risk factors
- 65-year-old man undergoing total colectomy with prior DVT and active cancer (Correct answer)
- 55-year-old woman with varicose veins undergoing cholecystectomy
- 70-year-old man undergoing hernia repair with BMI 32
Correct answer: 65-year-old man undergoing total colectomy with prior DVT and active cancer
Major abdominal surgery combined with age >60, prior DVT, and active malignancy yields a Caprini score ≥5, placing this patient in the highest-risk category for VTE.
Question 4: Which of the following laboratory values, if abnormal preoperatively, best predicts 30-day surgical mortality across multiple studies?
- Hemoglobin
- Serum albumin (Correct answer)
- Creatinine
- Platelet count
Correct answer: Serum albumin
Serum albumin is one of the strongest single-variable predictors of 30-day surgical mortality, reflecting overall nutritional status, hepatic synthetic function, and physiologic reserve.
Question 5: A 78-year-old man with dementia and multiple comorbidities requires right colectomy for T2N0 colon cancer. Which framework is most appropriate for a goals-of-care discussion about surgical risk?
- Present only survival statistics from NSQIP to family
- Shared decision-making incorporating patient values, functional goals, and realistic outcome expectations (Correct answer)
- Proceed with surgery as cancer prognosis drives the decision
- Defer the decision to the oncology team
Correct answer: Shared decision-making incorporating patient values, functional goals, and realistic outcome expectations
Shared decision-making incorporating the patient's values, functional goals, and realistic outcome expectations (including postoperative functional decline and nursing home risk) is the ethical standard for high-risk elderly patients.
Question 6: Intraoperative hypotension defined as MAP <65 mmHg for more than 5 minutes is most strongly associated with which postoperative complication?
- Surgical site infection
- Acute kidney injury (Correct answer)
- Anastomotic leak
- Postoperative ileus
Correct answer: Acute kidney injury
Intraoperative hypotension (MAP <65 mmHg) is most strongly and independently associated with postoperative acute kidney injury due to renal hypoperfusion, even in the absence of overt shock.
Question 7: Which of the following is the most appropriate definition of a 'near-miss' event in surgical patient safety?
- An adverse event that results in permanent patient harm
- An error that reached the patient but caused no harm
- An unsafe condition that was caught before reaching the patient (Correct answer)
- A sentinel event requiring root cause analysis
Correct answer: An unsafe condition that was caught before reaching the patient
A near-miss is an unsafe condition or error that was caught and corrected before reaching the patient, representing a critical learning opportunity for system improvement without patient harm.
General Surgery Board Review Risk Assessment & Management 5
Which of the following best describes the 'failure to rescue' metric as used in surgical quality improvement?