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Objective: This study identified failures in emergency inter-hospital transfer, or re-triage, at high-level trauma centers receiving severely injured patients. Background: The re-triage process averages 4 hours despite the fact timely re-triage within 2 hours mitigates injury-associated mortality. Non-trauma and low-level trauma centers reported that the most critical failures were in finding an accepting high-level trauma center. Critical failures at high-level trauma centers have not been assessed. Methods: This was an observational cross-sectional study at 9 high-level adult trauma centers and 3 high-level pediatric trauma centers. Failure modes effects analysis of the re-triage process was conducted in 4 phases. Phase 1 purposively sampled trauma coordinators, followed by snowball sampling of clinicians, operations, and leadership to ensure representative participation. Phase 2 mapped each re-triage step. Phase 3 identified failures at each step. Phase 4 scored each failure on impact, frequency, and safeguards for detection. Standardized rubrics were used in phase 4 to rate each failure's impact (I), frequency (F), and safeguard for detection (S) to calculate their risk priority number (RPN; IxFxS). Failures were rank-ordered for criticality based on their RPN. Results: A total of 64 trauma coordinators, surgeons, emergency medicine physicians, nurses, operations, and quality managers across 12 high-level trauma centers participated. There were 178 failures identified at adult and pediatric high-level trauma centers. The most critical failures were: (1) insufficiently trained transport staff (RPN = 648), (2) issues transmitting imaging from sending to receiving centers (RPN = 400), and (3) incomplete exchange of clinical information (RPN = 384). Conclusions: The most critical failures were limited transportation and incomplete exchange of clinical, radiologic, and arrival timing information. Further investigation of these failures includes several regions is needed to determine the reproducibility of these findings. [ABSTRACT FROM AUTHOR]