These front-line-driven improvements in the 10-bed Southmoor Emergency Room & UC demonstrate a sustained culture of safety, reliability and continuous process improvement. When door-

The team at AdventHealth ER & Urgent Care Southmoor, at 7000 E Hampden Ave, in Denver, Colorado.
July 21, 2026. Photo by Ellen Jaskol

to-EKG compliance for chest pain patients was only 50 percent, the team identified inconsistent communication between registration and clinical staff as the primary barrier. Nurses proposed

walkie-talkies to improve communication, which leadership supported. The Unit-Based Council partnered with registration, providers and nursing staff to implement a standardized STAT patient process for high-risk complaints, triggering immediate team response, rapid EKGs, telemetry and expedited rooming. Monthly data review demonstrated sustained improvement, increasing compliance to an average of 96 percent, exceeding the departmental goal and reinforcing nurse ownership, interdisciplinary collaboration and continuous process improvement.

Southmoor also established initiatives aimed at enhancing patient safety by using data to identify care gaps, engaging front-line staff and standardizing workflows. Staff-led audits, peer education and accountability initiatives fostered strong staff buy-in, increasing barcode medication scanning compliance from 88.6 percent to more than 98 percent, suicide screening accuracy from 84 percent to more than 97 percent, and fall risk assessment accuracy from 38 percent to 77 percent.