Quality and Patient Safety


We are the infrastructure that supports and inspires practitioners to provide the safest and highest quality patient care





Quality Assurance

Nathan Hudepohl, MD: Director of Quality and Patient SafetyNathan Hudepohl, MD: Director of Quality and Patient SafetyThe members of the quality team review all of the final microbiology/serology and radiology reports to ensure that positive lab results and important and incidental radiology findings are addressed and acted on appropriately. This often requires contacting patients, in-patient care teams or primary care doctors.

To aid us in the review of radiology reports, the Department of Emergency Medicine is working closely with the Department of Diagnostic Imaging to create and refine a "logic engine" which will help sort radiology reports based on the severity of the findings. This tool also allows us to track how we have closed the loop on these findings. This process of grading all radiology reports then using this "grade" to help prioritize action and follow up will likely become a best practice in radiology over the next decade.


Quality Improvement

There are many quality markers that we are required by the federal government to track and report. These indicators are tied to public reporting, meaningful use- and value-based purchasing. In addition, we have added additional indicators to track and report internally to promote best practices in the treatment of heart attack, stroke, sepsis and trauma care. Using a variety of educational, decision support, protocols and feedback tools to address our entire care team, we have seen significant improvement in quality markers that have translated into improvement in meaningful survival. Our efforts have been recognized by the hospital, the health care system, and the joint commission.



We support our front line clinicians by learning from our shortcomings and looking for opportunities to create and apply system fixes to prevent and mitigate harm to our patients. Recent projects include team work and  communication, universal protocol form redesign, automated notification to providers about patients who return to the ED within 72 hours, and reprogramming telemetry monitors to increase their visibility and reduce alarm fatigue.