Table 4.

Policy, caregiver roles and latent safety threat issues noted during: Issues noted during video reviewing

	Potential problems/negative impact
Communication
Not-verbalizing the reasons for initiating an intervention. e.g., intubation, chest compression, etc.	Lack of understanding the reasons behind an intervention, limits team members' ability to provide suggestions
Chest compression and PPV rhythm not verbalized “one and two and three and breathe”	Lack of synchronization delays neonate’s response to resuscitation
Heart rate is not verbalized after auscultating	Delay in making a decision on initiation/non initiation of chest compression
Excessive reliance on non-verbal communication, e.g., asking for a suction catheter by “stretching hands” after inserting the laryngoscope orally, as opposed to a “verbal request”	Delay in receiving suction catheter causes frustration in the intubator and delays the resuscitation efforts
Silencing alarms and not communicating the alarm to the team leader	Lack of awareness impedes accurate decision making and timely initiation of interventions
Team members not communicating assertively, e.g., Considering a higher peak inspiratory pressure in a non-responding infant	Delay in trouble shooting leading to ineffective resuscitation
Not sharing of relevant obstetric information with NR team during resuscitation of a depressed infant, e.g., MSL, abruption, Morphine	Delay in considering appropriate interventions, e.g., ET suction, fluid bolus and Naloxone respectively
Leadership
Leader was totally passive	Leads to momentary assumption of role by another member. Often results in delayed decision making, team losing focus, excessive indulgence in unnecessary interventions, e.g., suctioning, and lack of assessment of response to interventions
Fixation error, e.g., Making decisions of intubation and chest compression in a nonresponsive infant without ensuring good seal during mask ventilation	Unnecessary invasive interventions with a potential for adverse events
Lack of evaluation of plans during resuscitation	Prevents team members ability to provide suggestions
Team members positioning/configuration
Hands free team leader standing at the head end and RRTs who are on one side of the infant	Leader impedes effective delivery of mask ventilation
Initiating chest compression with the side walls up	Impedes effective performance of chest compression
Technical
Ineffective seal around the mask during mask ventilation	Delay in responding to resuscitation
Attempting nasal intubation while resuscitating an unresponsive infant with severe bradycardia	Potential delay in intubation
Not venting stomach after a prolonged mask PPV	Secondary deterioration in SpO2 and heart rate
Not vigilant about FiO2 during resuscitation. Started 100% FiO2 only after 90 s of chest compression	Delay in response to resuscitation
Extubation while securing the ET tube as ET tube is not held firmly against the hard palate during taping	Potential for secondary deterioration or delay in resuscitation

NR: Neonatal resuscitation.