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. 2023 May 1;94(5):739-742.
doi: 10.1097/TA.0000000000003886. Epub 2023 Feb 4.

TQIP mortality reporting system case reports: Unanticipated mortality due to communication and handoff failures

Regan F Williams  1 , Samuel P Mandell; ACS TQIP Mortality Reporting System Writing Group
Collaborators, Affiliations

TQIP mortality reporting system case reports: Unanticipated mortality due to communication and handoff failures

Regan F Williams et al. J Trauma Acute Care Surg. .

Abstract

The TQIP Mortality Reporting System is an online anonymous case reporting system designed to share experiences from rare events that may have contributed to unanticipated mortality at contributing trauma centers. The TQIP Mortality Reporting System Working group monitors submitted cases and organizes them into emblematic themes. This report summarizes unanticipated mortality from two cases of failure of communication and handoff, and presents strategies to mitigate these events locally with the hope of decreasing unanticipated mortality nationwide.

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