Perinatal High Reliability: Doing the Right Thing for Every Patient, Every Time


Poster Presentation

Purpose for the Program

High-reliability organizations operate highly complex and hazardous systems, essentially without mistakes. Safety is the hallmark of a high-reliability unit (HRU) and is understood to be the responsibility and duty of every team member. The purpose of this project is to implement the clinical and cultural changes required to establish our Women Infant Services units as HRUs.

Proposed Change

All clinicians have an obligation to speak up for safety. This project creates the environment and mechanisms that support team efforts to achieve safety. Activities are geared toward ensuring that quality issues are exposed to provide opportunities for prevention. Project activities include daily check-in meetings, increased leadership presence, implementing a process for timely and open review of safety incidents, and communicating findings and solutions to team members.

Implementation, Outcomes, and Evaluation

Daily check-in (DCI): DCI reviews the past 24 hours, looks ahead at the next 24 hours, and asks, “Are there any safety concerns?” The team includes charge nurses from the departments of labor and delivery, mother–baby (M/B), gynecology (GYN), antepartum, and neonatal intensive care unit; nurse management; physicians; social work; pharmacy; and anesthesiologists. In the first 10 weeks of DCI, 55 safety concerns were verbalized; 66% resolved the same day and 88% within 5 days.

Rounding to influence: Obstetric leaders round twice per month. Bedside nurses verbalize safety concerns and safety behaviors. STAR (stop, think, act, review) and ARCC (ask a question, make a request, voice a concern, and use the chain of command) behaviors are reinforced. Patient interviews give further opportunity to verbalize safety concerns.

High-Reliability Committee structure:

  • High-Reliability Committee: Accountability and transparency of safety, quality, and patient satisfaction measures.
  • Incident Report Committee (ISIS): Monthly meetings; bedside nurses review incident reports and make action plans.

Debrief/cause analysis: Critical safety events are brought forward within a week of occurrence. Participants assess the event from every angle looking for opportunities to improve and make action plans.

Safety newsletter: Monthly updates on action plans and safety concerns close the loop of communication.

Evaluation: Fall 2012 safety culture survey.

Implications for Nursing Practice

Within the safe culture of an HRU, the authority gradient is lessened and nurses experience decreased stress and increased respect for their contribution to the team. When unusual or unexpected events occur, nurses are empowered to improve bedside practice through the debriefing process and support from the team. Job satisfaction is increased on units where practice is based on evidence and professional standards.