Challenges and Models of Success for Patient Safety and Quality of Care


  • The author reports no conflict of interest or relevant financial relationships.


Audrey Lyndon, PhD, RNC, CNS-BC, FAAN, Assistant Professor, Department of Family Health Care Nursing, UCSF School of Nursing, 2 Koret Way, Room N411Y, Box 0606, San Francisco, CA 94143-0606.

The perinatal safety movement began in 1999 with the now classic publication “High Reliability Perinatal Units: An Approach to the Prevention of Patient Injury and Medical Malpractice Claims” in which the authors described the characteristics of high-reliability perinatal units (Knox, Simpson, & Garite, 1999). Early adopters used this model and applied human factors principles and the aviation principles of crew resource management to generate momentum focused on flattening hierarchies and improving teamwork in perinatal care (Leonard, Graham, & Bonacum, 2004). Momentum was generated by the series of Institute of Medicine (IOM) reports on safety and quality (IOM, 2001; Kohn, Corrigan, & Donaldson, 2000; Page, 2004), and the Joint Commission Sentinel Event Alert on Preventing Infant Death and Injury During Delivery further highlighted the contributions of communication breakdowns, poor teamwork, and other systems problems to serious and potentially preventable adverse outcomes in perinatal care (Joint Commission on Accreditation of Healthcare Organizations, 2004). Many organizations have made significant strides in advancing perinatal safety and quality in the intervening years (Burke, Grobman, & Miller, 2013; Pettker et al., 2009; Pettker et al., 2011; Simpson, Knox, Martin, George, & Watson, 2011), but challenges remain.

In 2011 the seven organizations that represent clinicians who care for women during labor and birth issued a joint Call to Action regarding quality care in labor and delivery that was simultaneously published in American Journal of Obstetrics & Gynecology, Journal of Obstetric, Gynecologic, & Neonatal Nursing, and Journal of Midwifery & Women's Health (Lawrence et al., 2012). The Call to Action outlined four shared principles of quality and safety: communication, shared decision making, teamwork, and quality measurement. In this In Focus series, the authors consider several different perspectives on the kinds of safety and quality dialogues that are needed to meet the principles outlined in the Call to Action. The authors address different aspects of the processes involved in informed and shared decision making, interdepartmental collaboration, and models of what can be accomplished when systems commit to effective collaboration.

In the first article, Jacobson, Zlatnik, Kennedy, and I provide the nurse's perspective on the quality of information women receive for making decisions during labor and birth as a safety issue and examine strategies nurses use to support women's decision making, advocate for women's preferences, and promote safety. We argue that team-based, woman-focused communication can support women's decision making during labor and birth. However, the persistence of traditional medical hierarchies and absence of interprofessional dialogue in maternity settings can lead nurses to use well-intentioned communication strategies that can have unintended negative consequences.

In the second article, Simpson addresses issues related to meeting women's desires for birth and explores the safety of birth under water. She presents a critical review of currently available literature and guidelines that clinicians might use in discussing the risks and benefits of underwater birth with women and their families. In light of insufficient evidence of benefit and case reports of neonatal harm, Simpson argues that the literature supports the current recommendations of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2012) that underwater birth take place only in the context of randomized controlled trials until safety and benefit can be established. She highlights one of the principles we must keep in mind in assessing the evidence for safety in the context of rare adverse events: the absence of adverse outcomes in underpowered studies does not mean that an intervention is “safe.”

In the third article, Chagolla, Keats, and Fulton outline the need for and some of the challenges involved in developing a comprehensive strategy for interdepartmental collaboration between the emergency department and obstetric units. The authors illustrate the challenges of making decisions about best practices in the face of identified clinical need, limited published evidence, and variation in settings, resources, and practice patterns. They provide recommendations for potential pathways to improving communication, patient flow, and interdepartmental collaboration in the care of pregnant women presenting to the emergency department.

In the final article, Raab, O'Mara, Will, and Richards wrap up the series with inspirational examples of the kinds of safety and quality accomplishments collaboration made possible across three institutions participating in a safety initiative. They highlight several important lessons by illustrating the application of central principles. First, collaboration is not a flavor of the month and does not simply mean getting along with each other in the work environment. Rather, collaboration is conceptualized in these organizations as an ongoing active, deliberate, and intentional process. Second, the programs described demonstrate the full, engaged commitment of administrative, medical, and nursing leadership that is necessary for transformational change. Finally, local control, frontline engagement, a spirit of equality, and access to data are essential to systematic improvements in safety.

Much of the local expertise described by Raab et al. and called for by Chagolla et al. is provided by nurses. These initiatives demonstrate the central role nurses play in patient safety and quality in maternity and newborn care. Yet the need for caution with respect to evidence and reflection on nursing practice strategies are also highlighted in this issue. Although much has been accomplished in the quest to improve safety for childbearing women and their families, much remains to be done to meet the Call to Action.


  • Audrey Lyndon, PhD, RNC, CNS-BC, FAAN, is an assistant professor In the Department of Family Health Care Nursing, UCSF School of Nursing, San Francisco, CA.