This presentation focuses on the criteria for At-risk for Wandering patients as defined by VHA Directive and on recommended actions/interventions to implement for patients attempting to elope or opting to leave against medical advice. All reported elopement events from CY21 and CY22 were reviewed with 12 and 9 events respectively identified to have met the At-risk criteria that were then further analyzed and included using a systematic approach which helped identify trends in the processes and develop actions geared towards mitigating potential risks and preventing incidents from reoccurring. An initial understanding of combined elopement/missing/wandering patient events were reconciled against triage questionnaire. This review utilized systematic approach and entailed literature and chart reviews, interviews, Subject Matter Expert (SME) consultation, and Gemba walk. Gaps were addressed and Cause and Effect diagram were developed using the 5 Rules of Causation. These provided contextual understanding of events, thereby assisting in the development of Root Causes following the CAUSE, EFFECT, EVENT statement. Safety initiatives to prevent incidence of elopement/wandering/missing include template updates, utilization of Vocera and Wander guard, annual Elopement Risk Assessment competency/tabletop drills, closed loop communication during handoff, policy/unit protocol changes, additional signage for elopement precautions in locked units, Benetravel Consult template updates and notification of expectations for At-risk veterans to contract community nursing homes (CNH). An Annual Patient Safety Assessment Tool (PSAT) on Wandering and Missing patients are completed which reflected missing patient events outlined separately per department as well as required annual Missing Patient Tabletop drills in the different areas of the hospital with marked 600% increase in drills from previous year. PSAT reflects measure of success as evidenced by lesser missing patient events the following year.