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Appropriate and timely triage is an essential component of a trauma system. In the state of Ohio, there are 6 verified pediatric trauma centers (PTCs) across 8 state regions. The purpose of this study was to better understand the pediatric undertriage rates in the state.We used the Ohio Trauma Registry from 2007 to 2012, consisting of 14,045 records of children younger than 16 years admitted to a hospital for more than 48 hours or who sustained a traumatic death. Pediatric undertriage was defined as not being directly transported to a PTC when one was available within 30 minutes or not being transferred to a PTC within 2 hours of injury.The state pediatric undertriage rate was 52%, only decreasing to 35% when up to a 4-hour transfer time was allowed. Across state trauma regions, undertriage rates varied from 94% to 40%. More than 28% of injured children had access to a PTC within 30 minutes of their home. A trauma center (adult or pediatric) was within 30 minutes for 66% of the children, yet 32% of the children went to a nontrauma center first. Overall, 29% of children never made it to a PTC, and 4% of children remained at a nontrauma center, with regional variation from 5% to 0.5%. Statewide mortality was nearly 3%, with regional variations between 5% and 0.4%. Mortality rate within the appropriately triaged group was 5.3%, while mortality rate in the undertriage group was only 0.7%. Overall, 53% of transferred patients had a more than 2-hour transfer time.Despite the significant number of PTCs in Ohio, there remains a high undertriage rate with significant regional variations and long transfer times. Continued analysis will be useful in furthering trauma system development for the injured child.Therapeutic/care management study, level IV; epidemiological, level IV.