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

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.