In the Literature: A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims

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

Simpson KR, Kortz CC, Knox E, A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims, The Joint Commission Journal on Quality and Patient Safety, 2009, 35(11), 565-74.

Name of Agency/Organization/Institution

16 perinatal units affiliated with Catholic Healthcare Partners (Cincinatti, OH)

Project Aims and Goals

The aim of the project was to align hospital practices with best evidence and professional guidelines and improve patient safety.

Approach and Activities

Perinatal safety consultants:

  • provided annual educational sessions covering best practices in perinatal care and risk reduction strategies for specific clinical situations associated with high risk of injury.
  • conducted in-depth perinatal risk assessments of all participating hospitals to evaluate clinical standards, safety, and professional culture.
  • provided each hospital a gap analysis detailing resources necessary to move all practices to be consistent with current evidence and national guidelines and standards

Recommendation focused on culture of safety, fetal assessment, labor induction, second stage care, and other labor and newborn care issues.


Between 2003 and 2008, birth trauma rates decreased from 5.0 to 0.17 per 1,000 births, the number of obstetrical occurrences (specified birth-related event or injury that may lead to a claim) decreased by 65%, from 7.2 to 2.5 per 1,000 births, and the average costs per obstetrical claim decreased from $1 million to < $500,000. The number of new claims reported decreased by 48%.

Blueprint Area(s) Addressed

Strategies used

Filed in Clinical audit, case review, or analysis of adverse events, Clinical practice guideline/policy change, Educational materials for health professionals, Improved liability system, In the Literature, Performance measurement, Performance measurement/reporting, Risk management/liability reform, Staffing/care coordination change, Team building on Sun., Apr 3, 2011

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