An interprofessional team was established to prevent tracheostomy-related acquired pressure injuries. The team performed an in-depth analysis of practice from tracheostomy insertion through postinsertion care. A literature evaluation identified best practices, and a root cause analysis for all tracheostomy-related pressure injury cases identified common causes. Lessons learned from the practice and literature reviews drove care standardization and reduced variation. Preimplementation and postimplementation data were analyzed to determine the effectiveness of improvement interventions. Improvement strategies included use of a more flexible tracheostomy tube, standardization of suturing, timing of suture removal, application of a hydrocolloid dressing at time of insertion and a foam dressing after suture removal, and caregiver education regarding early identification of and interventions for complications related to sutures and swelling. The result has been an 80% reduction of tracheostomy-related acquired pressure injuries systemwide.