1. Simpson, Kathleen Rice PhD, RNC, CNS-BC, FAAN

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In September, 2020, Liberati et al. (2020) published an important study on the characteristics of safe maternity units using multisite ethnography. Gathering these data was no small undertaking. This comprehensive and inclusive process involved over 400 hours of observations, interviews with 33 caregivers in six maternity units, consultation with 65 stakeholders via semistructured telephone interviews, and one focus group (Liberati et al., 2020). I was honored to participate as a stakeholder. Seven patient safety features of maternity units were identified. They include commitment to safety and improvement at all levels, with everyone involved; technical competence, supported by formal training and informal learning; teamwork, cooperation, and positive working relationships; constant reinforcing of safe, ethical, and respectful behaviors; multiple problem-sensing systems, used as basis of action; systems and processes designed for safety, and regularly reviewed and optimized; effective coordination and ability to mobilize quickly (Liberati et al., p. 1). Each of these characteristics of safety is collective, cumulative, and required to promote perinatal safety.


In 1999, after reviewing hundreds of adverse events and medical malpractice cases, we applied the principles of high reliability organizations (Roberts, 1990) to perinatal units and offered recommendations for safer care for mothers and babies in the inpatient maternity setting (Knox et al., 1999). Our findings are remarkably similar to Liberati et al. (2020). In a perinatal high reliability unit, safety is the hallmark of the organizational culture and a clearly stated purpose, operations of the system are based on the entire team, communication is highly valued with a flattened hierarchy, all members of the team are educated on the same underlying physiologic basis for fetal heart rate tracing interpretation and use the same language to communicate about them and other aspects of care, emergencies are rehearsed so teams know what to expect and how to quickly respond, and successful operations are constantly scrutinized because routines can lead to simplification and "normalization of deviance" (Knox et al., 1999; Knox et al., 2003). Twenty years later we are still finding significant gaps in safe care for mothers and babies in the inpatient maternity setting (Simpson, 2021). The study by Liberati et al. is very helpful in highlighting what continues to constitute a safe maternity unit, especially because they involved so many key participants in maternity care. It is now time to move beyond identification to adoption of safe practices to promote safer care.


Hierarchy remains a major problem as nurses are not always viewed as valued or respected members of the perinatal team. Professional communication by all professionals is not the norm in all practice settings. Disruptive clinician behavior continues by some members of the perinatal team. Disrespectful maternity care, social and health care inequities, bias, discrimination, systemic racism, and lack of true partnership with patients are significant barriers to safe maternity care. As the health care professional who provides the majority of direct patient care, nurses can take a leadership role in promoting perinatal patient safety. Participation in quality care collaboratives, adopting and supporting practices based on evidence and national standards and guidelines, achieving specialty certification, keeping up-to-date, belonging to and taking a leadership role in your professional organization, and role-modeling respectful maternity care behavior are strategies known to be associated with safer care and better outcomes (Simpson, 2021). Nurses are vital to safe care for mothers and babies.




Knox G. E., Simpson K. R., Garite T. J. (1999). High reliability perinatal units: An approach to the prevention of patient injury and medical malpractice claims. Journal of Healthcare Risk Management, 19(2), 24-32. [Context Link]


Knox G. E., Simpson K. R., Townsend K. E. (2003). High reliability perinatal units: Further observations and a suggested plan for action. Journal of Healthcare Risk Management, 23(4), 17-21. [Context Link]


Liberati E. G., Tarrant C., Willars J., Draycott T., Winter C., Kuberska K., Paton A., Marjanovic S., Leach B., Lichten C., Hocking L., Ball S.Dixon-Woods, for The SCALING Authorship Group. (2020). Seven features of safety in maternity units: A framework based on multisite ethnography and stakeholder consultation. BMJ Quality & Safety, September 25. [Epub ahead of print] [Context Link]


Roberts K. H. (1990). Some characteristics of high reliability organizations. Organizational Science, 1(2), 160-177. [Context Link]


Simpson K. R. (2021). Perinatal patient safety and quality. In K. R. Simpson, P. A. Creehan, N. O'Brien-Abel, C. Roth, & A. Rohan (Eds.), AWHONN's Perinatal nursing (5th ed.). Wolters Kluwer. [Context Link]