“You don’t know what you don’t know.” Our department’s ED Quality Assurance (EDQA) committee will celebrate its 4th  anniversary this September. By that time over 1,100 cases will have been reviewed by the roughly 10 individuals who make up this committee. Cases are obtained using both screening criteria (ED mortalities, return visits resulting in admissions) and open referrals from inside and outside the department. While most referrals are internal, many come from other hospital departments, private attendings, and patients\families. EDQA is our major tool for barriers to providing optimal care and improving patient and staff safety. The composition of the committee is key. It includes both ED nurses and physicians (including leadership) along with a representative from the hospital’s quality department. When appropriate,  representatives from other departments…