Zero-defects management is based on the premise that it is better to detect problems before they cause accidents or product defects. Airlines must use a zero- defects approach to maintaining and flying their planes. Everything is done and recorded by written protocol designed to identify problems before they become threats. Parts are replaced when they are worn but still safe rather than being allowed to fail. Judgment and art are critical in flying, but the objective is to recognize when they are necessary before it is too late for them to help. Medicine has the same problem. An obstetrician’s skill in managing a complication of pregnancy can be exercised only if the complication is detected while still treatable.

The foundation for a zero-defects approach in obstetric practice is a highly structured medical record integrated with standardized patient education materials. This record system should be self- prompting and self-documenting. The simplest way to achieve this is with a preprinted medical record form. This form tracks the patient’s care through time, with entries for every test and issue to be discussed with the patient. Most important, the patient educational materials are keyed to the protocol. For example, early in the pregnancy the patient receives information about the tests that will be performed during the pregnancy, including when they should be performed.

At 16 weeks, the record indicates that it is time for the MSAFP sample to be drawn, and a handout given to the patient. Even if the provider forgets to discuss the test and draw the sample, there is a high probability that the patient will remember the test and ask about it. The structured record both prompts the care provider and allows the patient to participate in the quality control for her own care.