Table 5.

Policy, caregiver roles and latent safety threat issues noted during: System issues noted during video debriefing

	Suggestions/solutions
No response from NICU front desk when called for additional help by resuscitation team in infant stabilization room	Avoid unmanned NICU front desk all the time
Preterm infant on CPAP transferred directly to NICU as opposed to stabilization in infant stabilization room and then to NICU	Transfer through stabilization room ensures that a ventilator and incubator is always ready for stabilization
Person attending resuscitation is different from the one who participated in team huddle	Case specific preparation and management plans discussed during team huddle becomes redundant
Difficulty in paging the resuscitation team members as the composition of resuscitation team changed during a shift	Dedicated resuscitation pagers to be carried by resuscitation team members as opposed to individual personal pagers
Infant stabilization room stocking was exhausted when 3 deliveries happened during a shift. Health care aides were replenishing stocks once a shift	Health care aides will be called to replenish stocks when necessary
Delay in sending the blood samples from infant stabilization room to lab	Tube system restored
Needle stick injury to a resuscitation team member while setting up the resuscitaire	Educate all caregivers to remove sharps after the procedures
Fall and injury to foot while running to attend a pink code in labor and delivery unit	Educate caregivers on taking precautions to avoid injury
Undue delay in starting a PIV in infant stabilization room due to non-availability of personnel	Educate RN team members about creating a backup support to establish PIV in time
Who is the first responder (MD/NP) to attend labor and delivery calls during handover? (8-9 am and 5-6 pm)	The day resuscitation team (MD/NP) members
Pending high-risk deliveries and family’s preference for resuscitation was not passed on to day team. Thus the day team was unclear about their roles when called to attend delivery	Should be an essential part of handover