Maternal harm is a sentinel event that has garnered increased attention in both policy and clinical environments. This qualitative study combined direct observation and interviews to understand the characteristics that enabled a high-performing maternity ward to achieve their excellent safety outcomes. Investigators identified a set of specific, evidence-based safety practices including standardization, monitoring, and emphasis on technical skill. They also identified a strong and consistent safety culture and noted that structural conditions, such as staffing levels and the physical environment, supported safe outcomes. The authors conclude that all of these factors influence each other and jointly produce safety. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.