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Background

Of the 3.9 million births in the United States each year, 2 percent are estimated to involve an adverse event; at least half are potentially preventable. A review by the Joint Commission found that between 2004 and 2014, poor communication was a root cause of 48 percent of sentinel maternal events and 70 percent of sentinel neonatal events. In addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication errors due to the frequent use of high-alert medications. And though obstetric emergencies are rare, they have the potential to result in catastrophic outcomes such as maternal or neonatal death if an appropriate clinical response is not provided in a safe, coordinated, and timely manner. Lastly, the use of inappropriate interventions, or interventions provided in an unsafe manner, also increases the risk of adverse events on L&D units. High-reliability systems and a culture of learning from errors (or near misses) are needed to minimize preventable harms.

AHRQ developed a comprehensive patient safety program that provides a platform and tools to improve patient safety in L&D units.

Project Partners

The program was coordinated by RTI International and involved experts from the following organizations:

• Medical Teamwork Consultants, LLC.
• National Perinatal Information Center (NPIC).
• University of North Carolina School of Medicine.

Reports (Resources)

• Safety Program for Perinatal Care Summary Report (PDF, 1 MB)
• Case Studies from AHRQ Safety Program for Perinatal Care: Experiences From the Frontline (PDF, 765 KB)