A convergence of events – published literature on causation of adverse events in maternal newborn care, claims analysis, a Joint Commission Sentinel Event Alert, and a lawsuit – galvanized our resolve at Hunterdon Medical Center to discover and address all issues that compromise the safety of our patients.  A wise person once said: “There is always more to the story.”  We have found that to be the case.  In this presentation we will share with you our story and some of the tools we have found most helpful in resolving and continuing work on our safety challenges.