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Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation
  1. Elisa Giulia Liberati1,
  2. Carolyn Tarrant2,
  3. Janet Willars2,
  4. Tim Draycott3,4,
  5. Cathy Winter4,
  6. Karolina Kuberska1,
  7. Alexis Paton5,
  8. Sonja Marjanovic1,6,
  9. Brandi Leach6,
  10. Catherine Lichten6,
  11. Lucy Hocking6,
  12. Sarah Ball6,
  13. Mary Dixon-Woods1
  14. The SCALING Authorship Group
    1. 1THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
    2. 2Department of Health Sciences, University of Leicester, Leicester, Leicestershire, UK
    3. 3Department of Translational Health Sciences, University of Bristol, Bristol, UK
    4. 4PROMPT Maternity Foundation, Bristol, UK
    5. 5Department of Sociology and Policy, Aston Medical School, Aston University, Birmingham, UK
    6. 6RAND Europe, Cambridge, Cambridgeshire, UK
    1. Correspondence to Professor Mary Dixon-Woods; director{at}


    Background Reducing avoidable harm in maternity services is a priority globally. As well as learning from mistakes, it is important to produce rigorous descriptions of ‘what good looks like’.

    Objective We aimed to characterise features of safety in maternity units and to generate a plain language framework that could be used to guide learning and improvement.

    Methods We conducted a multisite ethnography involving 401 hours of non-participant observations 33 semistructured interviews with staff across six maternity units, and a stakeholder consultation involving 65 semistructured telephone interviews and one focus group.

    Results We identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety). The features include: (1) commitment to safety and improvement at all levels, with everyone involved; (2) technical competence, supported by formal training and informal learning; (3) teamwork, cooperation and positive working relationships; (4) constant reinforcing of safe, ethical and respectful behaviours; (5) multiple problem-sensing systems, used as basis of action; (6) systems and processes designed for safety, and regularly reviewed and optimised; (7) effective coordination and ability to mobilise quickly. These features appear to have a synergistic character, such that each feature is necessary but not sufficient on its own: the features operate in concert through multiple forms of feedback and amplification.

    Conclusions This large qualitative study has enabled the generation of a new plain language framework—For Us—that identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units.

    • qualitative research
    • healthcare quality improvement
    • patient safety
    • obstetrics and gynecology

    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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    • Collaborators The SCALING Authorship group: Cathy Bevens; Lia Brigante; Kate Brintworth; Jenni Burt; Carol Carlile; Denise Chaffer; Sanhita Chakrabarti; Tracey Christmas; Victoria Clark-Ward; Sophie Clements; Joanna Crofts; Paul Davis; Lesley Deacon; Fiona Donald; Rachel Duckett; James M.N. Duffy; Charlotte Dyson; Sian Edwards; Diane Farrar; Matthew Fogarty; Mandy Forrester; Aidan Fowler; Richard Haddon; Robyn Halliday; Clea Harmer; Jill Houghton; Carolyn Johnston; Matthew Jolly; Tejinder Kaur-Desai; Tony Kelly; Joy Kirby; Karin Leslie; Sandy Lewis; Amanda Lindley; Louise Locock; Nuala Lucas; Audrey Lyndon; Nicola Mackintosh; Joanne Matthews; Bernadette McCulloch; Siobhan McHugh; Sarah Merritt; Edward Morris; Alison Nicol; Anita Patil; Rebecca Percival; Farrah Pradhan; Daniel Punch; Amanda Rowley; Catherine Roy; Elizabeth Russell; Magdalena Rzewuska; Kathleen Simpson; James Titcombe; Michele Upton; Gill Walton; Sascha Wells-Munro; Caitlin Wilson; Rebecca Wilson-Crellin; Alison Wright; Christopher Yau

    • Contributors EGL and MD-W drafted the original manuscript. All authors critically reviewed, revised and approved the final version. All members of the SCALING Authorship Group reviewed and approved the initial submission and had the opportunity to comment, and the final version was shared with them. MD-W is the guarantor.

    • Funding Health Foundation (THIS Institute), Wellcome Trust Senior Investigator Award (WT097899MA) and NIHR Senior Investigator Award (NF- SI-0617-10026).

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The study received ethical approval from the London – Harrow Research Ethics Committee. REC Reference: 17/LO/0740

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Our ethical approval does not allow sharing of primary data. Requests for data should be directed to Mary Dixon-Woods (PI for the project).

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