Trauma Quality Improvement Program mortality reporting system case reports: Unanticipated mortality due to delays in endovascular hemorrhage control

Samuel W Ross; Joseph R Buck; Aaron R Jensen; ACS TQIP Mortality Reporting System Writing Group

doi:10.1097/TA.0000000000004721

Trauma Quality Improvement Program mortality reporting system case reports: Unanticipated mortality due to delays in endovascular hemorrhage control

J Trauma Acute Care Surg. 2025 Jul 3. doi: 10.1097/TA.0000000000004721. Online ahead of print.

Authors

Samuel W Ross¹, Joseph R Buck, Aaron R Jensen; ACS TQIP Mortality Reporting System Writing Group

Collaborators

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

Affiliation

¹ From the Division of Acute Care Surgery (S.W.R.), Atrium Health Carolinas Medical Center, Charlotte, North Carolina; Section of Trauma and Critical Care Surgery (J.R.B.), Ascension St. John Hospital, Detroit, Michigan; and Department of Surgery (A.R.J.), University of California San Francisco, and UCSF Benioff Children's Hospitals, Oakland, California.

PMID: 40604366
DOI: 10.1097/TA.0000000000004721

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 a case of unanticipated mortality due to delays in obtaining endovascular hemorrhage control. We present strategies to mitigate these delays locally and decrease unanticipated mortality nationally.

Keywords: Embolization; hemorrhagic/therapy; medical errors/prevention and control; quality improvement; shock; therapeutic; wounds and injuries/therapy.