Facility policies:

Poor patient safety culture Inadequate nurse to neonate ratio Multiple neonates in a single patient incubator or warmer Exceeds facility capacity

General healthcare worker behaviors:

Low HCW (and caregiver) hand hygiene compliance Improper aseptic technique for device insertion Poor adherence to device and IV maintenance, care, and administration

Specialty healthcare worker behaviors:

Inadequate cleaning of non-critical items in contact with skin Inadequate sterilization or reprocessing of multi-use, semi-critical and critical items Improper sterile compounding of medication or fluids and improper multi-dose vial or solution use

Infrastructure and consumables:

Reuse of single use semi-critical and critical items Lack of alcohol-based hand rub at point of care Lack of running water, sink, soap and paper towels on ward