Excessive blood loss after childbirth is a leading cause of death for mothers if the bleeding is not caught in time.
It's also a big cause of medical malpractice lawsuits.
That's why a team of doctors, nurses, and others at the Hospital of the University of Pennsylvania worked through a simulation of postpartum hemorrhage on Tuesday with an actor posing as a live "patient."
"It mimicked the chaos" of real life, said Lauren Hughes, a nurse who participated in the training.
A lesson from the session - one of several a week at Penn Medicine on high-risk complications - was the importance of quick and efficient communication.
"Now we take all of our findings and do the work," said Kate O'Rourke, clinical practice leader for labor and delivery at HUP.
Such training has helped Penn cut malpractice costs by 26 percent since 2011, to $92.2 million in the year ended June 30, even as revenue has risen 28 percent, to $4.3 billion.
Temple University Health System has logged an even steeper decline in liability costs, to $11.3 million in fiscal 2015 from $48.1 million in 2011, records show.
When Fitch Ratings upgraded the credit rating of Holy Redeemer Health System last month, one factor was reduced malpractice insurance expense for physicians.
It's a different world from the early 2000s, when the malpractice insurance industry was in crisis, and politicians and others warned of a doctor exodus from Pennsylvania.
Experts said providers in the state have benefited from regulatory changes in 2003 making it harder to bring malpractice cases, and ended "venue shopping," the filing of cases in areas likely to result in high jury awards even if the incident occurred elsewhere.
"The second part of this that nobody talks about is the tremendous amount of effort and money being spent by providers in reducing cost, in reducing errors, in patient safety, employee safety," said Dominic Colaizzo, the Philadelphia-based chairman of Aon Risk Solutions. "I've seen a tremendous amount of change over the last 10 years."
Penn, even before adopting simulation training in 2009 in obstetrics and other high-risk areas, focused on improving patient communications.
It created an office of patient affairs in 2006 to identify complaints from patients while they were still in the hospital, said Patricia Sullivan, the system's chief quality officer.
Sullivan came to Penn in 2004, soon after Ralph W. Muller became the system's CEO, aiming to be proactive on malpractice, she said.
Patient affairs began working closely with Penn's general counsel when things went wrong to reach settlements.
"We've also gotten really aggressive at the same time to take things to court when we feel like the medicine is defensible," Sullivan said.
Transparency with patients and their families is key. If they "are treated differently up front when something happens, when a complication happens, or when an error happens, they are less apt to sue than if we pretend like it's the Watergate phenomenon, everything's a cover-up, and nobody talks to them," she said.
To improve direct care, Penn has created teams "where a doctor, a nurse, and a quality and safety professional work together to look at their safety issues, their complications, their patient satisfaction, and look to develop specific projects for their patient population," she said.
One result is that the number of malpractice claims filed in obstetrics, one of the highest risk areas, has fallen by half since the peak in 2006-08 period, Sullivan said.
Like Penn, Holy Redeemer uses simulations to learn from what medical director Hank Unger called "high reliability" fields such as aviation and nuclear power.
"Those are examples of industries that have been very, very successful at looking at process and procedures and policies to really decrease the frequency of errors," he said.
Clear communication during handoffs of patients from one caregiver to another is crucial to patient safety, Unger said.
Thomas Duffy, a plaintiff's lawyer in Philadelphia, agreed that hospitals have improved patient safety, but said the so-called malpractice crisis of the late 1990s and early 2000s put a chill on juries.
"It became harder for juries to find that doctors are responsible, and I think, in turn, it made lawyers who have to invest in these cases invest in fewer cases," he said.
Duffy said he declined 97 cases between March and September because the cases were too costly to fight for a small payout.
The malpractice climate in New Jersey is different, said Aon's Colaizzo, because there is a $250,000 cap on the hospital portion of damages unless a hospital employee is found negligent. Also, experts said, New Jersey doesn't have such aggressive plaintiff's lawyers and a history of juries granting large damage awards.
Nicholas Gaudiosi, president of Healthcare Providers Insurance Exchange, a Philadelphia malpractice insurer being sold to a Raleigh, N.C., rival, said the big cases won't go away, citing a $10.1 million verdict last week against the Children's Hospital of Philadelphia.
"As long as you have humans involved, you're going to have mistakes. It depends what we do with it and how we handle it as an industry, as an institution, that really affects the outcome," he said.