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 anticipated mortality that both had opportunity for improvement related to more timely provision of palliative care cases. We present strategies to mitigate these delays locally.