At ISQua’s 42nd International Conference in Dublin, Phunziro Rajabu presented his team’s poster, “From Under-Reporting to System Learning: A Sequential Quality Improvement Initiative to Enhance Incident Reporting Culture in a Malawian Paediatric ICU”.

Phunziro started with ACQUIRE in the 2025 Quality Improvement and Patient Safety Theory Leadership Cohort, and we met him in person at the 2025 ACQUIRE QI Leadership Forum. This year, Mercy James Centre took part in both 2026 cohorts of the ACQUIRE Quality Improvement and Patient Safety Experiential Leadership Programme.

Where it started

In the Paediatric Intensive Care Unit, staff were working hard, but incidents and near-misses were not being reported or learned from.

“It felt like we were firefighting instead of preventing fires,” he recalls.

In March 2025, a national accreditation review found the unit’s incident reporting rate was 0%.

“I realised that quality improvement isn’t just about data and audits. It’s about creating an environment where people feel safe to speak up.”

What ACQUIRE gave him

“It gave me the structure and the confidence to turn a complex problem into a series of manageable steps.”

The Plan-Do-Study-Act cycle taught him to test small changes one at a time. Learning with peers facing similar challenges shifted his thinking from “we can’t do this” to “how can we test this?”

What the team did

A root cause analysis found three barriers: a blame culture, a complex reporting process and no digital system. The team introduced daily safety huddles, then a simplified paper form, then a QR code tool for reporting from a phone.

Between April and July 2025, the reporting rate rose from 0% to 100%. The rate measures reports submitted against reports expected, so 100% means the system is fully used. Near-miss reporting rose from 0% to 45%.

“The real victory wasn’t the number; it was the culture shift.” Staff now describe reporting as part of their daily routine.

Dublin and next steps

The poster received journal invitations from the International Journal for Quality in Health Care and IJQHC Communications. The team has since added a real-time dashboard of safety metrics, and plans to expand to other units and invite families to report concerns.

Phunziro wants to support similar work across Malawi and beyond, and to involve patients and families in safety. “This is just the beginning.”

His message to the ACQUIRE community

“Never underestimate the power of a small, focused change. You don’t need expensive technology or massive resources to transform a system. You need a clear problem, a structured approach, and the courage to test, learn and adapt.”

“The PDSA cycle gave us a roadmap, but it was the culture we built, one of openness and psychological safety, that made the change stick. Keep testing. Keep listening to your teams.”

Thank you

Phunziro credits the nurses, doctors, aides, respiratory therapists and clerks of Mercy James Centre PICU as “the real champions of this work”. He also thanks his co-authors H. Reid, V. Hawire and Charles Jenya, his mentors at the Learning Centre for Quality Management, and the Malawi Ministry of Health.