TQIP mortality reporting system case reports: Unanticipated mortality due to inadequate preoperative ICU "clearance".

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 unanticipated mortality from a case of inadequate clearance by the intensive care unit service before surgical intervention in an injured patient and presents strategies to mitigate these events locally with the hope of decreasing unanticipated mortality nationwide.