*Latent Safety Threats*

Participation in *Simulating Success* revealed a total of four LSTs in our unit. The first LST identified involved the administration of epinephrine. Although the team was able to ascertain and give the correct dose of epinephrine utilizing the standard preprinted, weight-based drug calculation sheet, trainees reported that it took longer to find the right dose since that form contained multiple other drugs. One trainee suggested that because epinephrine is one of the drugs that is most commonly administered during resuscitation, the dosages for intravenous (IV) and endotracheal tube (ETT) administration should be listed on a laminated card and placed inside the NICU emergency tackle box. This tackle box is taken to all deliveries attended by a NICU nurse. The use of this card has allowed for more timely identification of the correct dose by weight and administration route, reducing time to administration (Figure 2).

**Figure 2.** Epinephrine Administration via Endotracheal Tube Dosing Card Inside the Tackle Box.

The second LST identified concerned the performance of neonatal resuscitation and initiation of oxygen therapy. Throughout multiple simulated scenarios, trainees had di fficulty in assessing the extent to which the simulated newborn required assistance with ventilation and displayed uncertainty as to the need for oxygen as guided by the Neonatal Resuscitation Program (NRP) algorithm. To assist trainees with timely evaluation and management, the simulation team placed laminated cards on the radiant warmers in Labor and Delivery that address the target hemoglobin oxygen saturation levels by minutes of age according to NRP guidelines [12]. Furthermore, cards depicting the mnemonic MRSOPA (used to indicate the six steps recommended to address inadequate ventilation) were placed on the radiant warmer (Table 1).

The third LST identified pertained to the resuscitation equipment. One of our simulated scenarios involved the response to a newborn in the normal newborn nursery in the Mother–Baby Unit who became dusky during a lab draw. The newborn needed to be moved from a crib to the radiant warmer for resuscitation. Trainees participating in the scenario noted that the equipment and supplies that were needed to treat the simulated newborn were scattered haphazardly in the drawer of the radiant warmer, making it di fficult to find them in a timely manner and potentially producing a negative impact on neonates requiring resuscitation (Figure 3).


**Table 1.** The Steps of MRSOPA (modified from the Textbook of Neonatal Resuscitation [12]).

**Figure 3.** Mother–Baby Radiant Warmer Drawer Before Simulation.

As a result, the NICU team assisted the clinical coordinators in that unit with reorganizing supplies and equipment and developing a checklist to ensure that everything needed to resuscitate a newborn is present (Figures 4 and 5).

**Figure 4.** Mother–Baby Radiant Warmer Drawer After Simulation.


**Figure 5.** Mother–Baby Radiant Warmer Checklist.

The fourth LST involved the process of stabilizing a newborn with gastroschisis. This scenario truly reflects a high-risk, low-volume situation for our teams as a newborn with gastroschisis has not delivered at our hospital in more than five years and few of our staff have practical hands-on experience in managing a newborn with this condition. During the review of this recorded scenario, the CAPE team noted that other hospitals manage the stabilization of newborns with this congenital malformation in a different manner. This prompted us to contact the pediatric surgeons at the children's hospital to which we typically transfer our surgical patients and inquire as to what procedure they prefer that we follow. This led to a change in our stabilization process to reflect these updated recommendations. We also modified our supplies and equipment based on that information and communicated these changes to all NICU staff via email, as well as during the staff huddles held prior to each shift. We also noted that our debriefings of this scenario provided an opportunity for staff to engage in rich discussions (essentially "debriefing themselves"); this activity has been shown to improve clinical reasoning that may translate to replicating debriefings in a real-life situation [13].
