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

Regan F. Williams; Samuel P. Mandell; Aaron R. Jensen; Frederic J. Cole; Kimberly A. Davis; Richard Dutton; Doulia M. Hamad; Jonathan I. Groner; David G. Jacobs; Samuel P. Mandell; Avery Nathens; Bhavin Patel; Samuel W. Ross; John W. Scott; Regan F. Williams

doi:10.1097/TA.0000000000003886

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

Regan F. Williams, Samuel P. Mandell, Aaron R. Jensen, Frederic J. Cole, Kimberly A. Davis, Richard Dutton, Doulia M. Hamad, Jonathan I. Groner, David G. Jacobs, Samuel P. Mandell, Avery Nathens, Bhavin Patel, Samuel W. Ross, John W. Scott, Regan F. Williams

Research output: Contribution to journal › Article › peer-review

1 Scopus citations

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.

Original language	English (US)
Pages (from-to)	739-742
Number of pages	4
Journal	Journal of Trauma and Acute Care Surgery
Volume	94
Issue number	5
DOIs	https://doi.org/10.1097/TA.0000000000003886
State	Published - May 1 2023
Externally published	Yes

Keywords

Quality improvement
cause of death
medical errors/prevention and control
trauma centers
wounds and injuries

ASJC Scopus subject areas

Surgery
Critical Care and Intensive Care Medicine

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10.1097/TA.0000000000003886

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Williams, R. F., Mandell, S. P., Jensen, A. R., Cole, F. J., Davis, K. A., Dutton, R., Hamad, D. M., Groner, J. I., Jacobs, D. G., Mandell, S. P., Nathens, A., Patel, B., Ross, S. W., Scott, J. W., & Williams, R. F. (2023). TQIP mortality reporting system case reports: Unanticipated mortality due to communication and handoff failures. Journal of Trauma and Acute Care Surgery, 94(5), 739-742. https://doi.org/10.1097/TA.0000000000003886

Williams, RF, Mandell, SP, Jensen, AR, Cole, FJ, Davis, KA, Dutton, R, Hamad, DM, Groner, JI, Jacobs, DG, Mandell, SP, Nathens, A, Patel, B, Ross, SW, Scott, JW & Williams, RF 2023, 'TQIP mortality reporting system case reports: Unanticipated mortality due to communication and handoff failures', Journal of Trauma and Acute Care Surgery, vol. 94, no. 5, pp. 739-742. https://doi.org/10.1097/TA.0000000000003886

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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.",

keywords = "Quality improvement, cause of death, medical errors/prevention and control, trauma centers, wounds and injuries",

author = "Williams, {Regan F.} and Mandell, {Samuel P.} and Jensen, {Aaron R.} and Cole, {Frederic J.} and Davis, {Kimberly A.} and Richard Dutton and Hamad, {Doulia M.} and Groner, {Jonathan I.} and Jacobs, {David G.} and Mandell, {Samuel P.} and Avery Nathens and Bhavin Patel and Ross, {Samuel W.} and Scott, {John W.} and Williams, {Regan F.}",

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AU - Jensen, Aaron R.

AU - Cole, Frederic J.

AU - Davis, Kimberly A.

AU - Dutton, Richard

AU - Hamad, Doulia M.

AU - Groner, Jonathan I.

AU - Jacobs, David G.

AU - Mandell, Samuel P.

AU - Nathens, Avery

AU - Patel, Bhavin

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AU - Scott, John W.

AU - Williams, Regan F.

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

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Keywords

ASJC Scopus subject areas

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