Human error and communication failures are

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1 Developing and Testing a Vaginal Delivery Safety Checklist Barbara A. True, Cindy C. Cochrane, Martha R. Sleutel, Patricia Newcomb, Paul E. Tullar, and James H. Sammons Jr. Correspondence Barbara A. True, MN, CNS, RNC-OB, C-EFM, Women and Children s Division, Texas Health Arlington Memorial Hospital, 800 W. Randol Mill Rd., Arlington, TX BarbaraTrue@TexasHealth.org Keywords communication neonatal resuscitation postpartum hemorrhage safety checklists shoulder dystocia teamwork vaginal birth vaginal delivery ABSTRACT Communication failures are the most common root causes of perinatal deaths and injuries. We designed and tested a Vaginal Delivery Safety Checklist to improve communication and assist delivery teams risk assessments and plans for potential complications of vaginal birth. Delivery teams found the checklist easy, convenient, and helpful. Teams completed the checklist within 2 to 3 minutes and showed improved teamwork, communication, and decision making. JOGNN, 45, ; Accepted December 2015 Barbara A. True, MN, CNS, RNC-OB, C-EFM, is a clinical nurse specialist, Women and Children s Division, Texas Health Arlington Memorial, Arlington, TX. Cindy C. Cochrane, MS, WHNP-BC, RNC-OB, is a perinatal women s health clinical educator, Texas Health Harris Methodist Fort Worth, Fort Worth, TX. Martha R. Sleutel, PhD, RN, CNS, is a nurse scientist, Texas Health Arlington Memorial, Arlington, TX. Patricia Newcomb, PhD, RN, CPNP, is a nurse scientist, Texas Health Harris Methodist Fort Worth, Fort Worth, TX. (Continued) The authors report no conflict of interest or relevant financial relationships. Human error and communication failures are the most common causes of death and injury throughout the health care system, including in obstetrics (Institute of Medicine, 1999; Lyndon et al., 2012, 2015; Lyndon, Zlatnik, & Wachter, 2011; Rabb, Brown Will, Richards, & O Mara, 2013). Almost two thirds of the identified root causes of perinatal death and injury are related to communication failures (The Joint Commission, 2004). Researchers who conducted an analysis of 10 years of data demonstrated that human error, communication failures, inadequate assessments, and leadership deficiencies remain the top root causes for perinatal and maternal death and injury (The Joint Commission, 2015). Checklists are well-known tools to improve team communication, reduce human error, and promote patient safety (Agency for Healthcare Research and Quality, 2014; Gawande, 2009), and checklists were integral parts of many successful obstetric patient safety initiatives (Clark et al., 2007; Clark, Belfort, Meyers, & Perlin, 2008; Clark, Meyers, Frye, & Perlin, 2011; Einerson, Miller, & Grobman, 2015; Pettker et al., 2009, 2014). Proponents of safety checklists suggest that their use fosters teamwork, empowers team members to speak up, standardizes practices, and reduces the need to rely on human memory (Agency for Healthcare Research and Quality, 2014; Bliss et al., 2012; Gawande, 2009; Haynes et al., 2009). Use of checklists enhances patient safety by providing a structure whereby team members can communicate with one another regarding goals and plans of care (Agency for Healthcare Research and Quality, 2014). Childbirth is one of the most frequent reasons for hospitalization in the United States (Buie, Owings, DeFrances, & Golosinskiy, 2010), yet there exists no simple one-page intrapartum safety checklist to promote team communication and simultaneously address the most common emergencies encountered during vaginal birth (shoulder dystocia [SD], unanticipated need for neonatal resuscitation [NNR], and postpartum hemorrhage [PPH]). In recent years, many obstetric checklists have been proposed (American College of Obstetricians and Gynecologists, 2012, 2013; California Maternal ª 2016 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses. All rights reserved. 239 Published by Elsevier Inc.

2 Developing and Testing a Vaginal Delivery Safety Checklist Human error and communication failures are the most common causes of death and injury throughout the health care system. Paul E. Tullar, MD, FACOG, is an associate professor, Department of Obstetrics & Gynecology, School of Medicine, Texas Tech University Health Sciences Center at Amarillo, Amarillo, TX. James H. Sammons Jr., MD, MS, FACOG, FACHE, is Chief Medical Officer, Texas Health Arlington Memorial, Arlington, TX. Quality Care Collaborative, 2015; Council of Patient Safety in Women s Health Care, 2015a, 2015b; Damos & Frank, 2015; Evenson & Anderson, 2015; Gobbo, Warren, & Hinshaw, 2015; Harvey & Dildy, 2012; Main et al., 2015; Roth, Parfitt, Hering & Dent, 2014; True & Bailey, 2016). However, each of these checklists addresses only a single obstetric complication, and only a few suggest the identification of women at risk during labor (California Maternal Quality Care Collaborative, 2015; Harvey & Dildy, 2012; Main et al., 2015; Roth et al., 2014). Even checklists with an intrapartum risk component do not require that these risks be reviewed together by the anticipated delivery room team. Several excellent bundles of care have also been developed (Association of Women s Health, Obstetric and Neonatal Nurses, 2014; Council on Patient Safety in Women s Health Care, 2015a, 2015b). However, these bundles also lack communication tools to help delivery teams identify women at risk and prospectively plan potential emergent care. The focus of current obstetric checklists and bundles of care has been on the clinical management of the emergency, which neglects the nonclinical aspects such as communication and teamwork skills (Edozien, 2015). Although clinical and nonclinical skills are needed to manage emergent situations, the most frequent root causes of maternal and infant morbidity and mortality are inadequate nonclinical skills, such as communication failures, leadership issues, and human factors errors (Institute of Medicine, 1999; Maxfield, Lyndon, Kennedy, O Keefe, & Zlatnik, 2013; The Joint Commission, 2004, 2015). Checklists designed as communication tools can have a powerful effect on the reduction of deficiencies in the nonclinical aspects of care through the creation of a shared mental model (Agency for Healthcare Research and Quality, 2014; Bliss et al., 2012; Deering, Tobler, & Cypher, 2010; Gawande, 2009; Haynes et al., 2009; Maxfield et al., 2013). A shared mental model helps teams communicate more effectively. It is the mutual knowledge about a situation that is shared among team members and is achieved through a process of structured communication. A shared mental model (a) ensures that team members know what to expect, (b) helps synchronize care, (c) ensures that everyone is on the same page, and (d) enables members to predict and anticipate one another s needs (Agency for Healthcare Research and Quality, 2014). Each component is critical to minimize the root causes of maternal and neonatal death and injury. The absence of intrapartum checklists specifically designed to minimize root causes of communication and teamwork failures represents a significant gap in patient safety. Shoulder dystocia, PPH, and unanticipated NNR are inherent risks for any vaginal birth and can occur even in women without risk factors. However, screening checklists can alert teams to women at greater risk and allow them to prepare in advance for potential emergencies. The vaginal delivery safety checklist (VaDS) does not purport to prevent or predict these emergencies, and tracking long-term outcomes was not the goal of this project. Because of the rarity of these obstetric adverse events, longer-duration studies are needed to determine the overall effectiveness of the VaDS checklist. However, other researchers who instituted team training, protocol standardization, and checklist use found remarkable reductions in the number of liability claims and the amount of liability payouts and reduced their Perinatal Adverse Outcomes Index scores (Clark et al., 2008, 2011; Pettker et al., 2009, 2014; Wagner et al., 2011). The VaDS checklist builds on and is an extension of these prior patient safety initiatives. In the interest of rapid dissemination for this identified patient safety gap, our goal was to develop, validate, and disseminate the VaDS checklist for other providers to use and test. The objectives of this study were to develop, validate, and pilot a simple vaginal delivery safety checklist with the following qualities: (a) facilitates team communication during labor to identify women at risk for three common complications surrounding vaginal birth (SD, NNR, PPH); (b) improves interdisciplinary team planning and helps develop consensus during labor about risks and evidence-based interventions for the identified complications; (c) targets the most common root causes of maternal and perinatal adverse outcomes (human error, communication failures, inadequate assessments, leadership deficiencies); and (d) is viewed by delivery room teams as easy, convenient, and helpful. 240 JOGNN, 45, ;

3 True, B. A. et al. P RINCIPLES & P RACTICE Methods Before implementation, this study was reviewed and approved by the institutional review boards at the three study sites. This study comprised three phases: (a) the development of the VaDS checklist and validation of its content, (b) the pilot of the VaDS checklist during actual births, and (c) an investigation of decision making of interdisciplinary teams as they used the VaDS checklist. Phase 1: Checklist Development and Validation In Phase 1, we conducted a rigorous review of English-language literature to identify risk factors and interventions for three common emergencies surrounding vaginal birth (SD, NNR, and PPH). Medline and CINAHL database searches targeted the underlying risks and management strategies for each emergency. To ensure content validity for this criterion-referenced checklist, we used standards of care and recommendations from key professional organizations (the American College of Obstetricians and Gynecologists, the Association of Women s Health, Obstetric and Neonatal Nurses, the American Academy of Pediatrics, the American Academy of Family Physicians, and the California Maternal Quality Care Collaborative). In addition, we conducted a review of patient safety literature. The VaDS checklist items were derived directly from the published research, standards, and recommendations for care. To evaluate agreement among team members with regard to interpretations of checklist items, we asked 20 experts (10 medical care providers [MCPs] and 10 labor and delivery [L&D] nursing providers) at two tertiary care facilities (5 MCPs and 5 L&D nursing providers per facility) to rate each item for relevance for each of the three obstetric emergencies. Experts were defined as those who were nationally board certified in their fields and had a minimum of 5 years current L&D experience. A purposive sample that represented a diverse range of providers was selected, including chairs and past chairs of obstetric departments, perinatologists, L&D nurses, certified nurse-midwives, and physicians from solo and group practices. Participants gave informed consent before they engaged in research procedures. For each potential emergency, experts rated each risk factor and intervention listed on the VaDS checklist on a scale from 0 (definitely not clinically important)to5(very definitely clinically important). In addition, raters provided qualitative feedback in Expert providers disagreed about well-documented risks and interventions that came from standards of care and professional guidelines, which indicated a need for an intrapartum safety checklist. the form of comments or suggestions for improvements, additions, or deletions. Data were entered by an investigator at each site and validated by a co-investigator from the alternate site. We determined the percentage of agreement for VaDS items for those items rated as definitely important or very definitely important (items scored 4 or 5). We also evaluated the differences in the distribution of medians for two groups (MCPs and nurses) using the Mann Whitney U test. We chose the Mann Whitney U, a nonparametric test, rather than an independent samples t test because, although responses on Likert-type scales are frequently treated as interval data, we preferred to treat these data as ordinal and to examine differences in medians rather than means. The Mann Whitney U test is analogous to the independent samples t test and is appropriate for ordinal level data, smaller sample sizes, and occasions when the data are not normally distributed (Polit & Beck, 2012). Microsoft Excel 2010 and SPSS Statistics version 21.0 were used for data analysis. Based on respondent feedback, we modified the checklist to a simple one-page format, with the risks for each emergency listed on one side and the corresponding interventions for those emergencies listed on the reverse (Figure 1). Phase 2: Checklist Pilot In Phase 2, we piloted the VaDS checklist to determine its usefulness and feasibility and the time needed to complete it. In addition, we investigated its effect on teamwork and team communication. The checklist was used at two tertiary care facilities by 108 providers (nursing and medical) in 36 births (18 births per facility). Neither of the sites employed 24-hour onsite obstetric hospitalists, which allowed us to investigate the use of the VaDS checklist in a more typical setting where MCPs are not always inhouse. The delivery team was a convenience sample of L&D nurses, the nurses who received newborns in the delivery room, and MCPs (physicians or certified nurse-midwives). Participants were instructed to use the VaDS checklist as follows: 1. The anticipated delivery team came together at a convenient time to review the VaDS checklist. This was done any time the JOGNN 2016; Vol. 45, Issue 2 241

4 Developing and Testing a Vaginal Delivery Safety Checklist Vaginal Delivery Safety Checklist Step One: Iden fy risk factors: Pa ent at Risk for Shoulder Dystocia? Does she have: Fetus at Risk for Addi onal Resuscita on? Does fetus have: Pa ent at Risk for Postpartum Hemorrhage? Does she have: Diabetes Category III or concerning FHR tracing Prior cesarean birth or uterine surgery (Gesta onal or Type 1 or 2) EFW > 4000 grams < 37 weeks gesta on Mul ple gesta on Prior shoulder dystocia Meconium fluid > 4 previous vaginal births Prior infant > 4000 grams PPROM Chorioamnioni s Maternal morbid obesity Narco cs within past 2-4 hours History of previous PPH (BMI > 40) Borderline/abnormal pelvis Chorioamnioni s Large uterine fibroids Short stature (Under 5 feet) IUGR Ac ve bleeding (> bloody show) A empt for opera ve vaginal Mul ple gesta on Suspicion of accreta/increta/percreta delivery planned TOLAC with history of CPD/FTP Maternal substance abuse Low lying placenta Medical or nursing provider Known fetal condi on/ Hct < 30 plus other risk factors concern malpresenta on/ anomaly Maternal obstetrical/ medical Platelets < 100,000 condi on Medical or nursing provider concern Known coagulopathy Opera ve vaginal delivery an cipated Prolonged second stage Use of Oxytocin for > 12 hours Treatment with Magnesium Sulfate YES YES YES Figure 1. Vaginal Delivery Safety Checklist. Used with permission from Texas Health Resources. 242 JOGNN, 45, ;

5 True, B. A. et al. P RINCIPLES & P RACTICE MCP and L&D nursing providers were all present on the unit. Teams were encouraged to review the VaDS checklist when sufficient information was available for adequate assessment of risk factors. This generally occurred during the active phase of labor when admission laboratory work results were available (if ordered) and the tolerance and progress of labor could be more accurately assessed. If MCPs with time constraints needed to review the VaDS checklist before the active phase, this was permissible as long as delivery team members could be face to face and there was sufficient information available to assess for maternal/fetal risk factors. This review occurred in a private location outside of the patient s room. 2. All team members expected to attend the birth (MCP, the mother s nurse, and the nurse who will receive the newborn at birth) were included in the checklist review. Members of the NICU team were involved if it was anticipated that they would attend the birth because of a potential need for more advanced NNR skills (e.g., prematurity, chorioamnionitis, known/suspected fetal conditions, etc.). The VaDS checklist was re-reviewed if team members changed, for instance, at change of shift or change of MCP. 3. The risk-side page of the VaDS checklist was reviewed first. Teams assessed risks for each of the three listed complications. All team members were encouraged to speak up and voice their opinions or concerns. 4. If risk factors were present, the team preplanned how they would manage the potential emergency by using the list of evidence-based interventions included on the reverse, intervention side of the VaDS checklist. If no risk factors were present for a complication, interventions were not reviewed. 5. The VaDS checklist was reviewed a second time near birth. This usually occurred when the MCP was called for delivery. Once all delivery team members were present, any team member asked, Has the checklist changed? If any team member believed there was a change in the patient s risks, the team reviewed the interventions and prospectively planned for the potential emergency. 6. The VaDS checklist could be initiated at any time by any team member (medical or nursing care provider) if there were new concerns about the patient. During the pilot, team members were asked to rate the VaDS checklist for three aspects: ease of use, convenience, and helpfulness. The rating scale ranged from 1 (not easy, not convenient, and not helpful) to 7(extremely easy, extremely convenient, and extremely helpful). Team members were also asked how many minutes it took to complete the VaDS checklist. This time frame was defined as the time the team spent together reviewing the checklist. We calculated a mean time using these data. Lastly, team members rated how the VaDS checklist affected teamwork and team communication using a rating scale from 1 (lowest) to 7 (highest). Phase 3: Checklist Decision Validity In Phase 3, we used a third site (tertiary academic hospital) to explore how the VaDS checklist would affect the decision making of the delivery teams. We assembled a convenience sample of three interdisciplinary delivery teams that included three to six members who had never seen the VaDS checklist. To ensure that these teams were representative of typical L&D teams, each team had a minimum of (a) one L&D nurse, (b) one nurse who received newborns during births, and (c) one obstetric and/or one family practice physician who provided obstetric care. Teams were assembled during their scheduled work hours and reviewed the case scenarios in a quiet area or room on the L&D unit. The different teams worked simultaneously on this project, and teams did not communicate with other teams during this process. The variance in team size (3 6 members) depended on unit busyness and members availability to participate. We provided each team with five different written summaries of the labors of women from Phase 2 (total of 15 summaries). Birth outcomes were not included. Teams were given instructions to review the summaries and, as a team, to identify risk factors for possible birth complications. An openended form was used to collect the teams assessments. One team member was assigned to serve as scribe and to record team responses. Two questions were asked on the data collection form: After reviewing the case summary, would you anticipate any complications for the mother and/or baby at the time of delivery? and If yes, what would those complications be? To assess the effect of the VaDS checklist on decision making, teams first assessed the five cases for JOGNN 2016; Vol. 45, Issue 2 243

6 Developing and Testing a Vaginal Delivery Safety Checklist This one-page safety checklist is quick and easy to use, and it improves the teamwork and communication of the delivery team by focusing assessments and guiding prospective care. risks without using the VaDS checklist and then reassessed the five cases using the checklist. The site investigator assessed the time it took for L&D teams assessments, first without the VaDS checklist and then with it. Because of the time involved for busy clinicians to review the summaries and to decrease respondent burden, we limited this phase to 15 cases. We analyzed data from these forms by comparing the number of potential complications identified with and without the VaDS checklist as well as the time it took for the team to come to consensus with and without the checklist. Results Phase 1: Checklist Development and Validation This phase evaluated agreement among experts (nurses and MCPs) on VaDS checklist items. For the total group, there was good agreement for interventions listed on the checklist, and 83% or more of experts rated these interventions as definitely important or very definitely important. There was less agreement for risk factor items, and 68% of these items were rated as definitely important or very definitely important (Table 1). With 5 as the highest rating (very definitely important), overall mean scores for all items ranged from 4.00 to 4.60 (Table 2). Intervention ratings were slightly higher and ranged from 4.37 to 4.60; risk ratings ranged from 4.00 to 4.12 (Table 2). Although overall agreement for VaDS checklist items was very good, there was notable disagreement between nurses and MCPs for risks and interventions for all complications (Table 2). There was a statistically significant difference between nurses and MCPs in all of their ratings except for risks for NNR (p ¼.243). Thus, nurses and MCPs did not agree on who is at risk or how that complication should be managed. This occurred despite the fact that each item on the checklist came directly from well-known, evidence-based standards of care, recommendations, and research. Phase 2: Checklist Pilot The VaDS checklist was used by 108 providers in 36 births. Each delivery team member rated the Table 1: Percentage of Expert Ratings of Vaginal Delivery Safety Checklist Items as Definitely or Very Definitely Clinically Important Medical Care Nurses Total Sample Category Providers (N ¼ 10) (N ¼ 10) (N ¼ 20) Shoulder dystocia Risks Interventions Neonatal resuscitation Risks Interventions Postpartum hemorrhage Risks Interventions feasibility and usefulness of the VaDS checklist during the pilot phase. On a scale of 1 to 7 with 7 as the highest endorsement, mean scores were 6.0 for ease of use, 4.9 for convenience, and 4.5 for helpfulness (Table 3). Most delivery team members (89%) reported that it took less than 3 minutes to complete the checklist, and 72% reported that it took less than 2 minutes. Team members perceptions of teamwork and team communication were also assessed. Of the three groups of team members, L&D nurses perceived the most benefit. Mean scores indicated that L&D nurses believed use of the VaDS checklist made them feel more prepared and more able to speak up for their patients. Scores also showed improvements in the perceptions of team members of team communication and team performance (Table 4). In addition, when the checklist was used, team members believed that details for care were noticed that ordinarily would have been missed (Table 4). Phase 3: Checklist Decision Validity At the third site, we examined the effect of the VaDS checklist on interdisciplinary delivery team decision making. Without the VaDS checklist, teams had difficulty with the identification of complications specific to vaginal birth and took as long as 40 minutes to come to decisions. For instance, teams reported possible difficult delivery or excessive weight gain rather than specifically identifying SD as the complication. Without the VaDS checklist, delivery teams identified a total of 54 potential 244 JOGNN, 45, ;

7 True, B. A. et al. P RINCIPLES & P RACTICE Table 2: Mean Ratings of Vaginal Delivery Safety Checklist Items Total Sample Medical Care Providers a Nurses a Statistical Significance b Category Shoulder dystocia Mean (SD) Mean (SD) Mean (SD) p Risks 4.12 (1.17) 3.84 (1.32) 4.39 (0.92).043 Interventions 4.60 (0.90) 4.33 (1.17) 4.88 (0.33).011 Neonatal resuscitation Risks 4.00 (1.15) 3.88 (1.14) 4.12 (1.14).243 Interventions 4.52 (1.00) 4.22 (1.22) 4.81 (0.57).0001 Postpartum hemorrhage Risks 4.07 (1.08) 3.77 (1.18) 4.37 (0.89).004 Interventions 4.37 (1.19) 3.99 (1.42) 4.76 (0.72).0001 Note. Scores ranged from 1 to 5, with 5 indicating very definitely clinically important. a Mann Whitney U test was used for medical care providers and nurses. b Level of significance set at p <.05. complications, yet only 17 (31%) of these were actually related to vaginal birth emergencies. When teams re-evaluated the case scenarios using the VaDS checklist, discussions were focused and lasted no more than 10 minutes, with teams able to quickly identify potential complications. In these 15 actual cases, 13 outcomes were uncomplicated, and 2 had SD. Without the VaDS checklist, teams did not identify either case as being at risk for SD. However, when they used the VaDS checklist, teams correctly identified both cases as being at risk for SD. Discussion The VaDS is a simple one-page checklist based on current standards, guidelines, and evidence. Delivery teams that used the VaDS checklist rated it as easy, convenient, and helpful, even in busy facilities that do not employ 24-hour onsite obstetric hospitalists. When they used the VaDS checklist, teams were more focused in their risk assessments and more successful in their identification of women at risk for birth complications than when they did not use the VaDS checklist. The VaDS checklist improved interdisciplinary teams decision making, communication, and teamwork. The VaDS checklist made the L&D nurses feel more prepared and more able to speak up for their patients. Root causes of perinatal and maternal injury and death are frequently related to communication failures; therefore, the improved communication between L&D nurses and MCPs with VaDS checklist use is an important finding. Although all VaDS checklist items were taken from widely published national guidelines, we found significant differences of opinions between nurses and MCPs on the importance of risk and intervention items. This lack of consensus among team members may lead to erroneous assumptions and increase the likelihood of Table 3: Means and Standard Deviations of Vaginal Delivery Safety Checklist Attributes Medical Care Providers Delivery Nurses Infant Nurses Total Sample Attribute Mean (SD) Mean (SD) Mean (SD) Mean (SD) Using VaDS was easy 5.7 (1.7) 6 (1.2) 6.2 (1.2) 6 (1.4) Using VaDS was convenient 5 (1.6) 5.2 (1.5) 4.4 (1.9) 4.9 (1.7) Using VaDS was helpful 4.4 (2) 5 (1.6) 4.2 (2) 4.5 (1.8) Note. Scores ranged from 1 to 7, with 7 indicating the highest level of endorsement. VaDS ¼ Vaginal Delivery Safety Checklist. JOGNN 2016; Vol. 45, Issue 2 245

8 Developing and Testing a Vaginal Delivery Safety Checklist Table 4: Teamwork Scores of Providers Using the Vaginal Delivery Safety Checklist Medical Care Providers Delivery Nurses Infant Nurses Total Sample As a result of using the VaDS checklist I felt. Mean (SD) Mean (SD) Mean (SD) Mean (SD) More prepared 4.6 (1.3) 5.2 (1.3) 4.3 (1.3) 4.7 (1.3) More able to speak up/advocate for the patient 4.7 (1.4) 5.1 (1.3) 4.1 (1.4) 4.7 (1.4) Team communication improved 5.1 (1.4) 5.2 (1.6) 4.4 (1.3) 4.9 (1.5) Team performance improved 5.0 (1.3) 4.9 (1.4) 4.4 (1.3) 4.7 (1.4) Details for care were noticed that ordinarily would have been missed 4.5 (1.6) 4.2 (1.7) 4.0 (1.5) 4.2 (1.6) Note. Scores ranged from 1 to 7, with 7 indicating the highest endorsement. miscommunications and poor team performance during emergencies. Optimal outcomes for mothers and newborns depend on timely, appropriate, and coordinated efforts by the delivery team. Tools that foster communication and cooperation among providers enhance patient safety and reduce errors. The use of the VaDS, a standardized, evidence-based checklist, to assess patient risk and assist team planning can minimize provider-specific biases and facilitate team consensus. The VaDS checklist creates a shared mental model among team members and eliminates the vulnerabilities of team members assumptions. Delivery teams rated the VaDS as easy, convenient, and helpful. Scores for helpfulness, although still high (4.5 on a 7-point scale), were lower than the other two variables. This may relate to perceptions of team members that they are already highly qualified and fully prepared for these emergencies. Therefore, they may not fully appreciate the critical role of nonclinical, teamrelated skills. Another factor may be that these adverse perinatal events are rare, and most teams did not experience complications during the pilot. Thus, the value of the checklist in identifying women at risk for complications and preparing teams for emergencies may have been less obvious in this small sample. Longer use of the VaDS checklist may change perceptions of helpfulness as teams encounter these emergencies and see the value of these nonclinical skills. One study site has used the VaDS checklist for over a year, and MCPs and L&D nurses have repeatedly commented on its value and helpfulness when these emergencies have occurred. These team members recount specific instances of how the VaDS checklist guided a smooth, coordinated team response as emergencies unfolded and cite the checklist as being the key component to the successful outcome. Limitations Because the study was conducted at two tertiary care hospitals and one academic medical center, generalizability to other maternity settings may be limited. Another limitation is the VaDS checklist s lack of generalizability to cesarean birth because of its design for vaginal delivery. Lastly, convenience sampling and a small sample of 36 vaginal births with 108 providers may introduce study bias; thus, a larger, longer study may provide different results. Long-term outcomes of the VaDS checklist were not investigated in this preliminary project. It was not within the scope or aim of this study to track long-term outcomes but rather to develop a checklist to meet an identified patient safety gap when no such checklist currently exists. Plans are now underway for a large, 13-hospital adoption of the VaDS checklist that will include all levels of obstetric care. With a larger, more diverse sampling and longer lengths of time to study the effect of the VaDS checklist, its value as an integral part of an obstetric patient safety program will be further explored. Conclusion The L&D unit is a fast-paced setting, where lifethreatening emergencies occur quickly and require a swift, coordinated interdisciplinary team response. To anticipate complications and plan for emergent care, team members need convenient, evidence-based tools that support a shared mental model and a same page approach. Our findings of discordance between and among expert care providers for well-known 246 JOGNN, 45, ;

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