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TQIP mortality reporting system case reports: Unanticipated mortality due to communication and handoff failures
Regan F Williams1, Samuel P Mandell,
1From the Division of Pediatric Surgery (R.F.W.), Le Bonheur Children's Hospital, and The University of Tennessee Health Science Center, Memphis, Tennessee; Division of Burn, Trauma, Acute and Critical Care Surgery (S.P.M.), UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas.
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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