Trauma Quality Improvement Program mortality reporting system case reports: Unanticipated mortality because of limitations in blood product availability

Rachel M Russo; Samuel P Mandell; Aaron R Jensen; ACS TQIP Mortality Reporting System Writing Group

doi:10.1097/TA.0000000000004690

Trauma Quality Improvement Program mortality reporting system case reports: Unanticipated mortality because of limitations in blood product availability

J Trauma Acute Care Surg. 2025 Jul 3. doi: 10.1097/TA.0000000000004690. Online ahead of print.

Authors

Rachel M Russo¹, Samuel P Mandell, Aaron R Jensen; ACS TQIP Mortality Reporting System Writing Group

Collaborators

ACS TQIP Mortality Reporting System Writing Group:
Joseph Buck, Frederic J Cole, Benjamin L Davis, Kimberly A Davis, Erin G Dawson, Richard P Dutton, Jonathan I Groner, Shailvi Gupta, Avery Nathens, Bhavin Patel, Samuel W Ross, John W Scott, Julie Y Valenzuela, Regan F Williams

Affiliation

¹ From the US Air Force (R.M.R.); Division of Trauma, Acute Care Surgery and Surgical Critical Care (R.M.R.), University of California Davis School of Medicine, Sacramento, California; Division of Burn, Trauma, Acute and Critical Care Surgery (S.P.M.), UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas; Department of Surgery (A.R.J.), University of California San Francisco, San Francisco; and UCSF Benioff Children's Hospitals (A.R.J.), Oakland, California.

PMID: 40604356
DOI: 10.1097/TA.0000000000004690

Abstract

The Trauma Quality Improvement Program 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 Trauma Quality Improvement Program Mortality Reporting System Working group monitors submitted cases and organizes them into emblematic themes. This report summarizes two cases of unanticipated mortality due to limited availability of blood products. We present strategies to mitigate these delays locally and decrease unanticipated mortality nationally.

Keywords: Quality improvement; blood transfusion; medical errors/prevention and control; shock, hemorrhagic/therapy; trauma center.