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Quality and Safety Program


The Department of Emergency Medicine's Quality Improvement Program was created in 2011 to provide a structure to oversee quality and safety initiatives for the department. The program participants strive to advance the quality of care delivered by University of Colorado Department of Emergency Medicine faculty and University of Colorado Hospital Emergency Medicine staff.


  • Eliminate avoidable harm to patients.
  • Empower and engage faculty and staff in building a “just culture” in order to improve care to patients.
  • Develop tools and provide faculty and staff with the skills necessary to deliver high quality and safe care to patients.
  • Identify and correct system failures that contribute to patient harm.
  • Train the next generation of healthcare providers to develop safety systems of care.
  • Foster an atmosphere in which quality improvement is valued as an essential component of the academic enterprise.


  • Emergency Medicine Continuous Quality Improvement Committee (EDCQI)
      • Interdisciplinary participation of Emergency Medicine faculty and staff who review departmental quality data and develop action plans to address. Representatives include physicians, advance practice practitioners (APPs), nurses, technicians, pharmacists, residents, process improvement staff, and administrative leadership representatives.  A sample of initiatives to date include: falls assessment program, mislabeled specimen program, novel alcohol withdrawl pathway, department metrics
  • Emergency Department Case Review Committee
    • A patient safety and peer review program which began as a pilot in 2012 has since become an institutional model. This interdisciplinary committee includes physicians, advance practice practitioners (APPs), nurses, technicians, pharmacists, residents, process improvement staff, administrative leadership representatives from the Emergency Department and other specialties who identify safety events and develop deliberate improvements in order to improve the delivery of care.
        • Emergency Department Resources:
            • EDCRC Tool Ki
            • Department of Emergency Medicine M&M Tool kit
            • Department of Emergency Medicine Quality and Safety Conference Tool Kit
  • Emergency Medicine Pathways Committee
    • In order to decrease practice variability and improve patient health outcomes the Department of Emergency Medicine has worked with numerous stakeholders and specialties to create over 40 clinical care pathways. These are based on the best medical evidence and used to guide care for practitioners. This committee helps to develop these pathways. 

Fellowship in Administration, Quality and Operations

The Department of Emergency Medicine in partnership with the Business School at the University of Colorado Denver have developed a fellowship in administration, operations and quality specifically designed to prepare future leaders by developing expertise in quality management, process improvement, human resource management, financial management, information technology, program development, observation medicine, ED operations, and overall leadership. Fellows in the program complete an Executive MBA in Healthcare Administration through the program on the downtown campus.


There are numerous quality, safety and process improvement scholarly projects ongoing in the Department of Emergency Medicine. In addition to faculty sponsored activities, there are numerous nursing credentialing, resident, advanced practice practitioner and pharmacist quality improvement scholarship projects. These include but are not limited to:
  • Creation of the IMPAS ED Event Review Trigger Tool® - PI Roberta Capp MD, MPH
  • Outpatient Treatment of Pulmonary Embolism and DVT – PI Kristen Nordenholz MD
  • Evaluation of Clinical Care Pathways in Patient Outcomes and Barriers to Implementation  - PI Jennifer Wiler MD
  • Development and Implementation of a ED Fall Prevention Tool – PI Robin Scott RN
  • Development of a Novel Alcohol Withdrawal Care Pathway – PI Jason Hoppe MD
  • Efficacy and Utility of Continuous Electroencephalography in Patients Surviving Cardiac Arrest – PI Sarah Perman MD
  • Point-of-Care Fascia Iliaca Blocks for Geriatric Hip Fracture Patients – PI Resa Lewiss MD
  • Implementation and optimization of identification and care of suicidal ED patients PI Marian (Emmy) Betz MD
  • Effectiveness of Epic Medication Alerts in the ED PI Andrew A. Monte MD
  • Encoding and processing patient allergy information in EHRs using Natural Language Processing – PI Foster Goss MD