Through front-line nurse collaboration and targeted one-on-one education, the UT Southwestern ED transformed pain reassessment performance from 35 percent in January 2023 to a

UT Southwestern Medical Center – William P. Clements Jr. University Hospital – Emergency Department

sustained compliance of greater than 80 percent. After identifying documentation gaps and reinforcing best practices through the “Don’t Forget Your PAST” initiative, scores increased to 69 percent by January 2025 and surpassed historic benchmarks by May 2025. Beyond the metrics, patients recognized the impact, with Press Ganey feedback highlighting timely pain relief, improved communication and a stronger focus on comfort, all of which demonstrated meaningful improvements in both patient safety and experience.

UT Southwestern’s 63-bed ED also improved its blood culture contamination rates by launching a performance improvement initiative after blood culture contamination rates reached 4.5 percent in December 2024. The team implemented CHG skin preparation, staff education and a dedicated RN/Tech two-person collection team. Through outstanding collaboration and front-line engagement, the ED achieved its goal of less than 2 percent contamination by February 2025, well ahead of its mid-year target. By the end of 2025, contamination rates were sustained at 1.9, reflecting the success of these interventions and the team’s commitment to patient safety, quality improvement and evidence-based practice.