Message from the CEO

Stephanie Peditto, MPSC CEO

Welcome to the new Mid-Atlantic Patient Safety Center newsletter and blog.

Despite decades of dedicated patient safety improvement efforts, many of today's most pressing risks extend beyond the walls of any single healthcare organization, requiring collaboration across the broader healthcare ecosystem. Read how the Mid-Atlantic Patient Safety Center is convening healthcare leaders, patients and families, industry, researchers, and policymakers to change the way we partner to make care safer for everyone.

At our Patient Safety Impact Summit earlier this year, we intentionally brought together leaders from health systems, industry, policy, research, and, critically, patients and families. That mix reflected a belief increasingly shaping our work: the most persistent patient safety challenges cannot be solved by healthcare organizations acting alone.

When I was first considering the opportunity to lead this organization, our Board Chair, Terry Fairbanks, shared something that has stayed with me. He spoke about the responsibility of the Patient Safety Center not simply to participate in the field, but to help move it forward—to focus our efforts where we can truly change outcomes rather than merely add to the status quo.

That expectation continues to guide how we think about our role.

A Changing Patient Safety Landscape

For decades, patient safety improvement has largely been built within the walls of individual healthcare organizations. To be clear, that work has mattered enormously.

Hospitals, health systems, and other providers have invested deeply in safety culture, event reporting, root cause analysis, high-reliability practices, workforce training, and improvement infrastructure. Clinicians, nurses, quality leaders, and patient safety professionals carry this work every day, often going above and beyond to protect patients in systems that are not always designed for safety.

Healthcare organizations must continue to identify risks, learn from events, strengthen systems, and adapt when conditions are imperfect. But that cannot be the endpoint.

If the broader healthcare ecosystem continues to generate conditions that make safety difficult to achieve, we will continue asking individual organizations—and the people working within them—to compensate for risks that should be addressed further upstream.

We are increasingly confronting a hard truth: improvement within individual organizations alone is yielding diminishing returns.

That is not because the work is not strong or the commitment is not there. It is because many risks patients face do not originate, and cannot be fully resolved, within a single organization.

Looking Beyond the Walls of Healthcare Organizations

Patient safety is influenced by the devices used at the bedside, technologies embedded in clinical workflows, electronic health record design, medication supply chains, staffing and resource constraints, payment structures, regulatory expectations, and the ways information moves—or fails to move—across settings.

Risks also travel across organizational boundaries. A patient may move from a physician practice to a hospital, rehabilitation facility, long-term care setting, pharmacy, home health provider, and back into the community. Each transition creates opportunities for information to be lost, responsibilities to become unclear, and risks to go unrecognized.

No single organization controls that entire journey.

Yet too often, we approach patient safety as though each provider can solve these challenges independently through greater vigilance, another policy, or one more improvement initiative.

That model places an extraordinary burden on the healthcare workforce. We depend on clinicians and staff to identify hazards, reconcile conflicting processes, compensate for poor design, and create workarounds that allow care to continue safely. Adaptability is an essential strength of healthcare, but we should not mistake constant adaptation for a well-designed system.

The question is not whether organizations should continue strengthening their internal patient safety efforts. They should.

The more important question is whether we can work across the ecosystem to reduce the conditions that require so much vigilance, adaptation, and workaround in the first place.

That is where organizations like the Mid-Atlantic Patient Safety Center have a distinct responsibility.

The Role of the Mid-Atlantic Patient Safety Center

We can create protected and trusted spaces for organizations to learn from one another. We can identify risks that appear across institutions rather than treating each event as isolated. We can bring together healthcare leaders, frontline teams, patients and families, researchers, policymakers, technology developers, manufacturers, and other partners who influence the conditions in which care is delivered.

We can also translate what we learn into practical action—shared tools, improvement strategies, policy recommendations, educational programs, and cross-sector partnerships that no single organization could build alone.

This is what we mean when we talk about expanding the patient safety ecosystem.

Looking Forward

Patient safety is not solely the responsibility of a hospital safety department or an individual care team. It is a shared obligation among everyone who designs, finances, regulates, supports, delivers, and experiences healthcare.

It also means ensuring that patients and families are not invited into the conversation only after harm has occurred. Their experience is essential to understanding how care functions across settings, where systems break down, and what meaningful improvement should look like.

As the Mid-Atlantic Patient Safety Center continues to evolve, this broader ecosystem perspective will remain central to our work. Our regional identity reflects both an opportunity and a responsibility to connect organizations and leaders across traditional boundaries, identify shared challenges, and accelerate learning throughout the region.

Through this newsletter and blog, you will hear from our team, healthcare leaders, patient and family advocates, researchers, and partners across the patient safety ecosystem. We will examine emerging risks, share lessons from protected learning and improvement work, highlight promising practices, and raise questions that deserve greater collective attention.

We will not pretend the answers are simple. Many of the most important patient safety challenges are complex, deeply embedded, and influenced by competing priorities. But complexity cannot become a reason to accept the status quo.

Meaningful progress will not come from asking every organization to try harder in isolation. It will come from working differently—across organizations, sectors, disciplines, and communities—to create a healthcare system that makes safe care easier to deliver and more reliable for every patient.

That is the conversation we hope to advance here. We invite you to subscribe, share these ideas, suggest issues that deserve greater attention, and reach out to the Mid-Atlantic Patient Safety Center to explore how we can work together to strengthen patient safety across the region.