Designing systems to reduce individual errors will improve maternity safety says RCM

on 14 July 2021 Midwives NHS Pregnancy Women Maternity Services Safety MSWs - Maternity Support Workers

Recognising that people make errors and designing systems to reduce the chances of this happening will improve maternity safety, says the Royal College of Midwives (RCM) publishing the third instalment in its Solution Series.

The Series is one of the RCM’s responses to the interim Ockenden Review published earlier this year, and other reviews of failed maternity services.

Making maternity services safer: Human factors, outlines what trusts and boards can do to organise and structure their services to reduce the chances of individual error as much as possible. It also provides a checklist for midwives and maternity support workers to reflect on how they work under pressure, with actions and practical tips to limit their chances of making an error.

Dr Mary Ross-Davie, the RCM’s Director for Professional Midwifery, said: “In order to improve safety in maternity care, it is really important that we understand the role of ‘human factors’. Human factors theory explains how people, however skilled, vigilant or dedicated will make mistakes. This way of approaching safety focuses on how we build environments, systems, resources and cultures that reduce the chances of these mistakes, making the right thing to do is the easiest thing to do.”

“This is not just a job for the individual or maternity services alone, it is one for the whole trust or board. It must come from the very top down and from the very bottom up for this to work effectively.”

Dr Ross-Davie added, The aviation industry has pioneered this approach to improve safety in their industry and shown it can work. Using similar methods can help to make maternity care safer. Many factors lead to people making mistakes and  affect  decision making,  such as the environment they work in, the equipment they are using, noise levels, stress from work pressures and fatigue. The challenge and the aim is to put systems and checks in place for organisations and individuals that offset these things, so the chances of mistakes are as low as possible.”


To contact the RCM Media Office call 020 7312 3456, or email [email protected]

Notes to Editors

The RCM Solutions Series 3 - Making Maternity Services Safer: The Human Factor can be read on the RCM website at Publications (

The RCM has a module on human factors in its i-learn online learning platform for RCM members at

Read Solution Series 1 – Improving Maternity Services:

Read Solution Series 2 – Making maternity services safer: the role of leadership:

The RCM is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team. We provide workplace advice and support, professional and clinical guidance, and information, and learning opportunities with our broad range of events, conferences, and online resources. For more information visit the RCM website.