Tools for establishing a sustainable safety culture within maternity services. A retrospective case study.

Objective: This article reports the findings from a single case study on the long-term sustainability of a quality system in a large maternity unit.

Method: The empirical basis is an analysis of documents related to the development, implementation, maintenance and outcome of the system over two decades. The main elements of the quality system are reported as findings, and the possible effects of the different elements are presented and discussed based on theories on safety management and leadership.