Patient Safety Doesn't Happen in Isolation. Neither Should Our Efforts to Improve It. Why partnerships—and the role of state governments—matter in patient safety.

Perspectives of Stephanie Peditto, President & CEO, Mid-Atlantic Patient Safety Center

Healthcare organizations are expected to deliver safe care, and rightly so. They are accountable for identifying risks, responding when patients are harmed, and making changes to prevent similar events.

But many patient safety challenges, from emerging AI risks to medical device problems and failures in transitions of care, extend beyond any one organization. 

Even well-resourced providers may lack the information, expertise, or influence to address them. A medical device problem, for example, may require engaging a manufacturer who isn't part of the conversation. Smaller providers may have even less ability to engage those partners. We continue to ask organizations to improve reporting, strengthen processes, and prevent harm, but some problems simply cannot be solved within their own walls.

Sometimes what healthcare organizations need most isn't another requirement. It's a partner.

Lengthening the Table

At the Mid-Atlantic Patient Safety Center (MPSC), we've been talking about "lengthening the table"—bringing more people and organizations into the work of patient safety to tackle problems they cannot solve independently.

A safety risk identified in one hospital or nursing home may be relevant to dozens of others. A solution developed in one setting may help another avoid months of trial and error. The value of bringing people together is what we do differently as a result. Making that happen consistently requires relationships and infrastructure that support shared learning across organizations.

In this and upcoming posts, I'll explore some of the partnerships needed to make that possible, starting with state government.

Why State Governments Matter

State governments have an important role in shaping healthcare priorities. Through their regulatory, payment, public health, and policy levers, they can influence the direction of healthcare and focus attention on areas needing improvement. But translating broad priorities into meaningful changes in patient safety requires collaboration with providers and others who can identify risks, understand what contributes to harm, and develop practical solutions.

Regulation and accountability are necessary, but they are not the same as helping organizations become safer. Regulation establishes baseline expectations and identifies where organizations fall short. It doesn't necessarily provide the actionable data, expertise, relationships, or practical support needed to understand why something went wrong and prevent it from happening elsewhere. Healthcare organizations need both accountability and support for improvement. These are different but complementary responsibilities, and an independent patient safety center can help bridge that gap.

Building on Maryland's Commitment

Maryland recognized the importance of statewide patient safety infrastructure more than 20 years ago when it established a patient safety center. That was an important commitment, and one worth building on.

Different parts of state government contribute to that commitment. The Maryland Health Care Commission (MHCC) helps shape statewide healthcare priorities, the Office of Health Care Quality (OHCQ) provides essential regulatory oversight, and the Maryland General Assembly influences policy and the resources available to support a patient safety center. Their responsibilities differ, but each has a role in creating the conditions for safer care. MPSC can help connect those efforts with the practical work of learning and improvement across healthcare organizations.

As MPSC has evolved, we've increasingly focused on challenges requiring a coordinated response. We're exploring how Maryland and other states in the region can more systematically learn from serious patient safety events, identify patterns, and share actionable findings. We're bringing stakeholders together to consider stronger patient safety learning infrastructure for nursing homes. And we're working with partners to help healthcare organizations recognize and respond to emerging AI-related safety risks.

These efforts have something in common: no single organization has all the answers. MPSC's role isn't to duplicate the work of regulators, professional associations, or providers. It's to connect those efforts, bring additional expertise to the table, and address gaps that might otherwise go unrecognized.

We don't need more organizations independently working on the same patient safety challenges. We need to get better at connecting the work already underway and bringing in more partners who can help develop solutions.

What Comes Next

Maryland has an opportunity to build on its longstanding commitment to patient safety by strengthening the connections between state agencies, policymakers, healthcare providers, and the organizations that support them. The goal isn't to create more oversight or another set of requirements, but to make better use of the expertise, information, and resources already available to address shared safety challenges.

State government can influence priorities and resources. Providers understand how care is actually delivered. MPSC can help connect those perspectives, identify common risks, and support learning across organizations.

But these are only some of the voices we need at the table. In future posts, I'll explore other partnerships and the different capabilities they bring to improving patient safety.

We won't eliminate preventable harm through partnerships alone. But we can make better use of the knowledge, experience, and resources that already exist across our healthcare system. That's what lengthening the table is really about. It's not about asking everyone to do more on their own. It's about making it possible to accomplish more together.