I am a cardiothoracic anesthesiologist and intensivist, and I spend most of my days caring for some of the sickest patients in the state. During my training and now career, I have noticed that the sickest patients, who require the most care, are more often the victim of medical error. Sometimes, these errors derail the plan of care and lead to poor outcomes. Along the way, I began to believe that improvements in healthcare delivery could have a greater impact on patient survival than almost any single pharmacologic or surgical discovery. In my early career at Washington University (Wash U, St. Louis), I was part of a multi-disciplinary and multi-specialty committee that examined patient safety issues. Witnessing firsthand what can be accomplished with a team approach solidified my resolve to maintain a team-oriented approach in future endeavors. While at Wash U I also participated in a multi-center project examining medication safety in the operating room (SCA Foundation, Peer-to-Peer). When I arrived at UTSW, I looked for areas that could benefit from process improvement. I first participated in a grant-funded project focused on improving transitions of care (handoffs) from the cardiac OR to the cardiac surgery ICU (CVICU) at Clements University Hospital (ECHO-ICU). The project used core quality improvement principles to develop the re-designed process, and one of the outcomes that were to be measured was voluntary event reports (specifically related to handoffs). I took ownership of this part of the project, as it dovetailed with my interest in ultimately reducing preventable medical error. At that point in time, early 2015, event reporting in our ICU was relatively infrequent and was highly variable from month to month. I worked with the Clinical Safety team at Clements, as well as the CVICU nursing staff, to implement multiple interventions aimed at increasing the rate of reporting. I also lead a team through UTSW’s ‘Clinical Safety and Effectiveness’ course, with a project focused on increasing event reporting in the CVICU. These staged interventions have led to a steady and sustained improvement in error reporting that continues today. I am qualified to conduct this research project because I have the clinical experience as an intensivist, as well as quality improvement training and experience, to see what the potential next steps in this journey are. In addition, my commitment to a multi-disciplinary and multi-specialty approach to research will ensure that I have the appropriate subject matter experts to help develop the most impactful intervention.