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