Lessons Learned from the First Hospital-Wide Neonatal Resuscitation Program Mock Code: Enhancing Patient Safety in Neonatal Resuscitation : Journal of Clinical Neonatology

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Lessons Learned from the First Hospital-Wide Neonatal Resuscitation Program Mock Code: Enhancing Patient Safety in Neonatal Resuscitation

Almudeer, Ali; Taha, Ibrahim1; Alarifi, Mohammed2; Temsah, Mohamad-Hani3

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Journal of Clinical Neonatology 12(2):p 75-76, Apr–Jun 2023. | DOI: 10.4103/jcn.jcn_10_23

Dear Editor,

Health-care systems need to adopt evidence-based approaches to provide optimal care for vulnerable neonates, as the first few minutes of a newborn’s life can have a significant impact on their future well-being and that of their family and community.

The Saudi Central Board for Accreditation of Healthcare Institutions[1] endorses the Neonatal Resuscitation Program (NRP) training,[2] but the hospital-wide NRP code implementation needs to be tested through mock codes. The first NRP Mock Code was conducted in a tertiary care facility in Riyadh, Saudi Arabia, in January 2023. The use of simulations has become crucial during the COVID-19 crisis and is expected to continue to play a significant role in the post-COVID-19 era.[3] The feedback from the NRP Mock Code can guide other hospitals globally in empowering their neonatal resuscitation teams.


The Cardiopulmonary Resuscitation (CPR) Committee at KKUH conducted the first NRP Mock Code on January 19, 2023, to evaluate the effectiveness of the NRP code for neonatal resuscitation. The high-fidelity simulation recreated a cardiac-pulmonary arrest scenario to identify gaps in the response and resuscitation process. The aim was to promote patient safety and ensure system integration in the hospital. The mock code was developed in response to concerns raised in mortality and morbidity meetings about delays in response due to system failures with code activation.


The mock code team prepared an empty patient room for a simulation. The neonatal intensive care unit (NICU) staff was not informed. The primary nurse was given a scenario of normal delivery, but the baby was delivered flat, not breathing, and with no tone. The NRP code was announced, and two nurses from the L and D ward started the initial resuscitation steps. The NICU team arrived within one minute, designated physicians for compression and ventilation tasks, and assigned nurses to handle medications. Immediate intubation was done, and epinephrine and volume expander were given. After 5 min, the baby revived (heart rate 120 and O2 sat 85%). The adult/pediatric crash cart and neonatal emergency box were brought in. Actions taken were recorded by the nursing supervisor [Table 1].

Table 1:
Neonatal Resuscitation Program Mock Code record

Table 1 observations included several notable points. The operator staff took one minute to answer due to unfamiliarity with the NRP code. MR. SOPA, the acronym used in neonatal resuscitation to guide healthcare professionals through a step-by-step process, was not considered before intubation. Overall, the team’s response exceeded expectations. Team dynamics were adequate but could improve by defining specific roles. Alarmingly, the “patient” experienced 42 seconds without compression during intubation. The respiratory therapist’s (RT) response was delayed by 5 minutes. A CO2 detector was not used to confirm endotracheal intubation. The current crash cart items and CPR sheet were suboptimal for neonatal resuscitation, with revised policy approval pending.


To promote patient safety during NRP Mock Codes, immediate feedback/debriefing should be provided, along with repetitive internal codes and the addition of respiratory therapists to the NRP Code Team. Regular training on minimizing interruption time and effective ventilation is also recommended.[4] NRP and other life support courses should be integrated into residency programs;[5] to strengthen the leadership skills of pediatric residents in NICU and DR.


We are grateful to the colleagues who contributed to this first NRP Mock Code, especially Dr. Fahad Al-Sohime and Prof. Bader Al-Sobaih.


1. CBAHI. CBAHI National Hospitals Standards Available from:https://www.scribd.com/doc/90204707/CBAHI-Standards# [Last accessed on 2023 Feb 08].
2. . AAP. Textbook of Neonatal Resuscitation 8th ed USA AAP 2021 Available from: https://publications.aap.org/aapbooks/book/694/Textbook-of-Neonatal-Resuscitation [Last accessed on 2023 Feb 08].
3. Temsah MH, Alrabiaah A, Al-Eyadhy A, Al-Sohime F, Al Huzaimi A, Alamro N, et al. COVID-19 critical care simulations:An international cross-sectional survey. Front Public Health 2021;9:700769.
4. Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ, et al. Teaching teamwork during the neonatal resuscitation program:A randomized trial. J Perinatol 2007;27:409–14.
5. AlSohime F, NurHussen A, Temsah MH, Alabdulhafez M, Al-Eyadhy A, Hasan GM, et al. Factors that influence the self-reported confidence of pediatric residents as team leaders during cardiopulmonary resuscitation:A national survey. Int J Pediatr Adolesc Med 2018;5:116–21.
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