Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety

      In a health care delivery system with an annual delivery rate of approximately 220,000, a comprehensive redesign of patient safety process was undertaken based on the following principles: (1) uniform processes and procedure result in an improved quality; (2) every member of the obstetric team should be required to halt any process that is deemed to be dangerous; (3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint; (4) malpractice loss is best avoided by reduction in adverse outcomes and the development of unambiguous practice guidelines; and (5) effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments. Since the inception of this program, we have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization
        Neonatal and Perinatal Mortality, 2006.
        • Clark S.L.
        • Belfort M.A.
        • Hankins G.D.V.
        • Meyers J.A.
        • Houser F.M.
        Variations in the rate of Operative Delivery in the United States.
        Am J Obstet Gynecol. 2007; 196: 526-527
        • McMahon M.J.
        • Luther E.R.
        • Bowes W.A.
        • Olshan A.F.
        • Bowes Jr, W.F.
        Comparison of a trial of labor with an elective second cesarean section.
        N Eng J Med. 1996; 335: 689-695
        • Landon M.B.
        • Hauth J.C.
        • Leveno K.J.
        • et al.
        Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.
        N Eng J Med. 2004; 351: 2581-2589
        • Hale R.W.
        • Harer W.B.
        Elective prophylactic cesarean delivery.
        ACOG Clin Rev. 2005; 10: 1-15
        • Foley M.E.
        • Alarab M.
        • Daly L.
        • et al.
        Term neonatal asphyxial seizures and peripartum deaths: Lack of correlation with a rising cesarean delivery rate.
        Am J Obstet Gynecol. 2005; 192: 102-108
        • Matthews T.G.
        • Crowley P.
        • Chong A.
        • McKenna P.
        • McGary C.
        • O'Regan M.
        Rising cesarean section rates: a cause for concern?.
        BJOG. 2003; 110: 346-349
        • Resnik R.
        Can a 29% cesarean delivery rate possibly be justified?.
        Obstet Gynecol. 2006; 107: 752-754
        • Clark S.L.
        • Hankins G.D.V.
        Temporal and demographic trends in cerebral palsy—fact and fiction.
        Am J Obstet Gynecol. 2003; 188: 628-633
      1. Frye V. United States 26.293 F. 1013 (DC Cir 1923).

      2. Daubert V. Merrel Dow Pharmaceuticals, 509 US 579 (1993).

        • Wennberg J.E.
        Unwarranted variations in healthcare delivery: Implications for academic medical centers.
        BMJ. 2002; 325: 961-965
        • Six Sigma
        Variation—the root of all process evil.
        • Clark S.L.
        • Belfort M.A.
        • Saade G.A.
        • et al.
        Implementation of a conservative checklist-based protocol for oxytocin administration: Maternal and newborn outcomes.
        Am J Obstet Gynecol. 2007; 197 (480e1–5)
      3. Gould SJ. Full house: The spread of excellence from Plato to Darwin. New York (NY): Three Rivers Press. p. 112–32.

        • Beyea S.C.
        Highly reliability theory and reliable organizations.
        AORN J. 2005; 81: 1319-1322
        • Rochlin G.I.
        Reliable organizations: Present research and future directions.
        J Contingency Crisis Management. 1996; 4: 55-59
        • National Transportation Safety Board
        Press release SB-05-09.
        National Transportation Safety Board, Washington (DC)2005 (March 29)
        • Degani A.
        • Weiner E.L.
        Cockpit checklists: Concepts, design and use.
        Hum Factors. 1993; 35: 28-43
        • Liker J.
        The Toyota way: 14 management principles from the world's greatest manufacturer.
        McGraw-Hill, New York (NY)2004
        • American College of Obstetricians and Gynecologists
        Vaginal delivery after a previous cesarean birth.
        American College of Obstetrician and Gynecologist Committee Opinion #143, 1994 (October)
        • Leung A.S.
        • Leung E.K.
        • Paul R.H.
        Uterine rupture after previous cesarean delivery: Maternal and fetal consequences.
        Am J Obstet Gynecol. 1993; 169: 945-950
        • Clark S.L.
        • Belfort M.A.
        • Dildy G.A.
        Reducing obstetric litigation through alterations in practice patterns—experience with 189 closed claims.
        Am J Obstet Gynecol. 2006; 195: S118
        • Asch S.M.
        • Kerr E.A.
        • Keesey J.
        • et al.
        Who is at greatest risk for receiving poor quality health care?.
        N Engl J Med. 2006; 354: 1147-1156