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Perinatal Patient Safety Project: A Multicenter Approach to Improve Performance Reliability at Kaiser Permanente

McFerran, Sharon PhD, CPHQ, RN; Nunes, Julie MS, CPHRM, RN; Pucci, Duayna MSN, MHA, RN; Zuniga, Anita MSN, RN

The Journal of Perinatal & Neonatal Nursing: January-March 2005 - Volume 19 - Issue 1 - p 37–45
Feature Articles

High-reliability organizations, including high-reliability perinatal units, are built on a solid foundation of timely communication and collegial teamwork to maintain patient safety as a top priority. In these units, concise, real-time, and constant communication is valued. Teamwork and collegiality characterize the professional relationships and hierarchy is minimized. The Perinatal Patient Safety Project utilized human factors techniques and systems improvements to create high-reliability perinatal units within a 1-year pilot project. This article focuses on the approaches used to improve communication in 4 Kaiser Permanente medical centers participating in this project.

Perinatal Patient Safety Project, Kaiser Permanente, Northern California Region.

Corresponding author: Sharon McFerran, PhD, CPHQ, RN, Perinatal Patient Safety Project, 1950 Franklin St, 14th Floor, Oakland, CA 94612 (e-mail:

The Garfield Memorial Fund provided funding for the Perinatal Patient Safety Project. Tony Devencenzi, MFT, CEAP, developed the Employee Assistance Program debriefing protocol known as the Critical Incident Response to Adverse Outcomes program. The Kaiser Permanente National Patient Safety Department was the source of the SBAR concept developed by the US Navy. The authors thank everyone at all sites involved in the Kaiser Permanente National Perinatal Patient Safety Project, a multicenter effort to improve communications and safety and recipient of Kaiser Permanente's 2004 Lawrence Patient Safety Award. The Kaiser Foundation Hospitals Medical Editing Department provided editorial assistance.

Submitted for publication: November 2, 2004; Accepted for publication: November 23, 2004

© 2005 Lippincott Williams & Wilkins, Inc.