Hospital-acquired pressure injuries are among the most preventable yet persistent sources of patient harm. This session will showcase how UPMC Western Maryland implemented a multidisciplinary, hospital-wide initiative that used data, root cause analysis, evidence-based prevention strategies, and workflow redesign to dramatically reduce HAPI rates across the continuum of care. Attendees will learn how cross-functional collaboration, targeted interventions, enhanced documentation, and continuous monitoring helped the organization outperform national benchmarks while creating a sustainable model for pressure injury prevention that can be adapted by other healthcare organizations.

A NICU admission is typically an unplanned event that can leave the family with undue stress related to the separation of an infant from the new parents. Skin-to skin (STS), the practice of placing an unclothed infant in direct contact with the mother or other caregiver’s bare chest, can alleviate the stress of separation, and improve bonding and parental autonomy. At Greater Baltimore Medical Center, NICU leaders identified that infants were not receiving the benefits from early initiation of STS due to great variability in the time it took for the first STS to occur. Standard work was designed, and barriers were identified through simulation and parental involvement to promote STS care within 24 hours of birth.

Preventing avoidable hospital readmissions requires early intervention and coordinated care across the continuum. This session will highlight how Baltimore Washington Medical Center implemented an innovative Emergency Department Transitional Nurse Navigator model that identifies high-risk patients during ED visits and connects them with the clinical and community resources needed to safely avoid hospitalization whenever appropriate. Attendees will learn how automation, multidisciplinary collaboration, and proactive care coordination reduced readmissions, increased safe discharges, and improved outcomes by addressing both clinical needs and the social drivers of health.

As patients increasingly rely on personal medical technologies, including insulin pumps, continuous glucose monitors, CPAP devices, wearable monitors, and other connected or implanted devices, healthcare organizations face new questions about how these devices should be assessed, documented, monitored, and managed during care. Patient-owned devices can support continuity and patient autonomy, but they may also introduce risks related to device compatibility, staff competency, medication management, cybersecurity, communication, and unclear responsibility for device operation. Join colleagues from across the region for a PSO-protected Safe Table discussion focused on real-world events, near misses, and operational challenges involving patient-owned medical devices. Participants are encouraged to share cases and lessons related to admission and medication reconciliation, criteria for continued device use, patient and caregiver responsibilities, transitions between personal and hospital equipment, documentation, escalation pathways, vendor interaction, and post-event review. Together, we will explore how organizations are developing safer, more consistent approaches while preserving the benefits these technologies offer to patients.

Preventing hospital-acquired pressure injuries demands a culture of accountability, collaboration, and continuous improvement. This session will explore how Carroll Hospital achieved a 64% reduction in reportable HAPIs through a multidisciplinary, data-driven quality improvement initiative. Attendees will learn how standardized prevention practices, real-time performance feedback, frontline engagement, and innovative technology were combined to strengthen compliance, improve patient outcomes, and create a sustainable model for pressure injury prevention.

This course presents a high-level orientation to the breadth of human factors engineering and a selection of specific skills. Participants will gain exposure to core knowledge of the domain and given an opportunity to apply human factors tools, along with an orientation to how the concepts could be applied to healthcare and specifically patient safety initiatives. Event Location: Mid-Atlantic Patient Safety Center 6820 Deerpath Rd Elkridge, MD | 21075

Medication safety improvements must come from practical changes that strengthen systems rather than single interventions. Join three local healthcare organizations as they share medication safety pearls and lessons learned from initiatives that enhanced medication use processes through technology, safety culture improvement, and multidisciplinary collaboration. Leave with practical strategies and actionable ideas that can be adapted to improve medication safety in your own organization.

This session will describe Sinai Hospital’s quality improvement initiative to standardize smoke evacuation across operating rooms by redesigning workflow, supply chain processes, education, and multidisciplinary accountability. The project included removal of non-evacuation electrocautery pencils, standardization of smoke evacuation setup, competency-based education, champion-supported coaching, and leadership support from surgery and anesthesia. Participants will learn how a system-level approach helped shift smoke evacuation from an optional practice to the default standard of care, resulting in improved compliance, universal device availability, completed nursing education, and reported reductions in odor and irritation.

This in-person interactive training equips healthcare professionals with the knowledge and skills to apply Failure Modes and Effects Analysis (FMEA) to proactively identify and mitigate risks in clinical processes. Participants will explore the history, purpose, and proven applications of FMEA, including its role in driving patient safety and meeting compliance requirements. By the end of the session, participants will be ready to integrate FMEA into their organization’s safety and quality programs to maximize patient care outcomes.

Safety event reporting systems are a foundational component of organizational learning, yet many healthcare organizations struggle with fragmented platforms, overly complex reporting processes, and inconsistent event classification structures. In this webinar, LifeBridge Health and Adventist Health will share their approaches to improving event reporting and creating systems that better support safety, quality, and continuous improvement.

Medication reconciliation remains one of the most challenging and consequential patient safety processes across the continuum of care. Breakdowns during admission, transfer, discharge, or transitions between care settings can result in omitted medications, duplicate therapies, dosing errors, and harmful drug interactions. Despite widespread implementation of medication reconciliation processes, organizations continue to struggle with obtaining accurate medication histories, clarifying discrepancies, engaging patients and caregivers, and integrating technology into safe medication management. Join colleagues from across the region for a PSO-protected Safe Table discussion focused on real-world medication reconciliation events, near misses, and successful improvement strategies. Participants are encouraged to share cases involving transitions of care, high-risk medications, communication breakdowns, health information exchange, pharmacy involvement, patient-owned medication lists, and EHR workflow challenges. Together, we will explore practical approaches to improving medication reconciliation reliability, strengthening interdisciplinary collaboration, and reducing preventable medication-related harm through shared learning in a confidential environment.

The three-day Lean Six Sigma Green Belt course equips healthcare professionals with the essential tools and methodologies to improve patient care, reduce inefficiencies, and enhance operational performance. This course provides a comprehensive understanding of Lean and Six Sigma principles, focusing on data-driven decision making, process optimization, and waste reduction within healthcare settings. Participants will learn to identify areas for improvement, implement sustainable solutions, and lead quality improvement projects that drive measurable results. Through real-world case studies and hands-on exercises, healthcare professionals will gain the skills needed to enhance patient outcomes, streamline workflows, and foster a culture of continuous improvement in their organizations. This course has been submitted for nursing continuing education, and will award approximately 18 contact hours. Credit hours are subject to accreditation approval following content review.

Preventing catheter-associated urinary tract infections requires reliable systems, not just individual vigilance. This session will highlight how the Adventist Healthcare Rehabilitation team dramatically reduced CAUTIs by embedding catheter necessity reviews, evidence-based hygiene practices, and interdisciplinary accountability into everyday workflows. Attendees will learn how simple, sustainable process changes transformed safety culture, reduced device utilization, and created a replicable model for achieving zero harm in the post-acute care setting.

The Root Cause Analysis (RCA) course provides healthcare professionals with the knowledge and skills to systematically investigate and address the underlying causes of medical errors, adverse events, and process inefficiencies. This course covers proven RCA methodologies, including the use of tools like the Five Whys, Fishbone Diagrams, and Failure Mode and Effects Analysis (FMEA), to identify root causes and implement effective corrective actions. Through case studies and practical exercises, participants will learn how to enhance patient safety, improve clinical processes, and foster a culture of proactive problem-solving. By the end of the course, healthcare professionals will be equipped to lead RCA initiatives that drive meaningful and sustainable improvements in their organizations.

The three-day Lean Six Sigma Black Belt course gives Lean Six Sigma Green Belts the confidence to design and implement better processes by analyzing the data rather than the gutfeel. Lean Six Sigma Green Belts who have demonstrated their knowledge initiating and completing at least one project will gain further knowledge to lead efforts to reduce process variations and improve results.

This in-person interactive training equips healthcare professionals with the knowledge and skills to apply Failure Modes and Effects Analysis (FMEA) to proactively identify and mitigate risks in clinical processes. Participants will explore the history, purpose, and proven applications of FMEA, including its role in driving patient safety and meeting compliance requirements. By the end of the session, participants will be ready to integrate FMEA into their organization’s safety and quality programs to maximize patient care outcomes.

This is a 4-hour virtual TeamSTEPPS® training session designed to strengthen teamwork and communication among healthcare professionals. TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) is an evidence-based framework developed by AHRQ and the Department of Defense. It is a nationally recognized program that supports clinical teams in optimizing performance and improving patient outcomes. This condensed course is tailored to healthcare team members who want a general overview of TeamSTEPPS® tools, offering actionable strategies to improve coordination, reduce errors, and enhance team resilience in dynamic care environments.

The Mid Atlantic Patient Safety Center and the MedStar Health National Center for Human Factors in Healthcare invites you to join us in developing a strategic approach to understanding, addressing, and advancing AI safety, with a focus on fostering collaboration, sharing best practices, and developing practical resources for organizations at every stage of AI adoption.

Join us as we spotlight three attendee-selected poster presentations from the Mid-Atlantic Patient Safety Conference. Each team will have 15 minutes to share the key insights, lessons learned, and practical takeaways from their work, followed by time for discussion and questions. From innovative improvement strategies to system-level approaches for safer care, these rapid-fire presentations will highlight ideas that resonated with healthcare professionals across the region and offer inspiration for future patient safety efforts.

Patient privacy extends beyond protecting health information—it also means ensuring critical clinical information reaches the right care team. Learn how Adventist Home Care's Health Information Management team partnered across departments and with an external laboratory to address the persistent problem of misdirected lab results. Through data-driven improvement and cross-organizational collaboration, the team achieved a 95% reduction in misdirected results, strengthening patient privacy, improving the reliability of clinical communication, and reducing risk to patient care. This session will share the team's approach, key lessons learned, and strategies for sustaining improvement.