In the Literature: HCA reduces liability claims, cesarean sections with comprehensive patient safety approach

This project was selected from among many reported in the peer reviewed literature. For a list of more articles on quality improvement, visit our resource bibliography.

Article Citation

Clark SL, Belfort MA, Byum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199(2): 105e1-7. [abstract]

Name of Organization, Agency, or Institution

Hospital Corporation of America

Project Aim and Goals

“This review reports on interventions that have been effective in our organization in addressing challenges to the following: (1) reduce perinatal morbidity and mortality; (2) reduce unwarranted cesarean sections; (3) reduce malpractice loss; and (4) assure safe, highly reliable individual practice.” (p. 105)

Approach and Activities

The general approach described in this article is the standardization of practices and protocols for several clinical situations associated with high risk of injury or harm, specifically use of oxytocin, misoprostol, or magnesium sulfate; operative vaginal delivery; and the management of shoulder dystocia and abnormal fetal heart rate tracings. The hospital system developed and implemented highly specific, checklist-driven protocols, procedure documentation templates, and mandatory online educational modules. Several of the check-lists are reprinted in the full text article, which is available by subscription. In addition to process standardization, every member of the maternity care team was required to halt any process when a patient was deemed unsafe.

Other aspects of the approach to safety include restrictive use of instrumental vaginal delivery and oxytocin, strict protocols for immediate availability necessary staff for VBAC labors, and a national peer review committee that reviews all unexpected adverse outcomes and issues recommendations to the providers and facilities involved.


In the period since the implementation of the comprehensive patient safety program, HCA saw a dramatic decrease in malpractice claims and loss rates. In addition, the primary cesarean section rate fell despite a generally liberal approach to operative delivery. Data suggested that the reduced use of cesarean was attributable to fewer abnormal fetal heart tracings in labors involving artificial oxytocin.

Blueprint Area(s) Addressed

Strategies Used

Filed in Care coordination, Clinical audit, case review, or analysis of adverse events, Clinical practice guideline/policy change, Educational materials for health professionals, Health professions education, Improved liability system, In the Literature, Performance measurement/reporting, Risk management/liability reform, Team building on Tue., Mar 15, 2011

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