Human factors lessons from a neonatal emergency in an unfamiliar space
Neonates magnify everything: good practice, bad habits, noise, hierarchy, hesitation.
When things go wrong, they do so quietly and quickly. This case reminded me that some of the biggest risks to tiny patients aren’t physiological at all — they’re human.
The scenario
I was working on a Children’s Assessment Unit when I was called to assist with a neonatal crash in A&E – an unusual location for neonatal resuscitation and one that immediately created friction between people, process and place.
The resus area was crowded: three doctors and a nurse at the neonatal resuscitaire, combined with at least six other professionals in the background.
A&E staff were least familiar with neonatal care;
NICU staff were least familiar with the environment and equipment.
No team leader was clearly identified. The baby’s ABCs were stable: pink, crying, and breathing spontaneously. Oxygen was being given. The immediate focus was venous access – three doctors attempting cannulation simultaneously, with no closed-loop communication and repeated requests for equipment that wasn’t bedside. The baby was distressed. The mother was present and had not been spoken to. The classic setup for error was already forming.
You’re the A+E doctor; you have a neonate requiring resuscitation, no one can get access, there are around 10 people talking over each other, no one is giving any instructions, everyone has forgotten about mum, and it feels very chaotic.
Pitfall 1: No leader ≠ no leadership
Without a named team leader, leadership emerged in fragments – task-based, reactive, and uncoordinated. Early on, I chose not to interrupt venous access attempts as they were close to success and critical to care. Instead, I built situational awareness from the periphery: collateral history, informal handover, parallel equipment preparation.
But leadership without explicit declaration is fragile. When attempts failed, uncertainty grew. Only then did I introduce myself clearly by name and role and request a handover.
In adult emergency medicine, the Team Leader role is clearly emphasised across all emergencies, from medical to trauma scenarios.
This shouldn’t change in paediatric and neonatal care
Learning
If you’re stepping into a resus – especially across specialities – say who you are and why you’re there early. Leadership doesn’t need to be authoritarian, but it does need to be visible.
The Trap: No Leader Named.
Leadership was reactive and task-based. No one declared they were in charge.
The Fix: Make Leadership Visible.
Step in early. State your name and role. You don’t need to be authoritarian, but you must be visible.
Pitfall 2: Task fixation and duplication
Once venous access became difficult, task fixation took hold. Even after agreement that one clinician should attempt access, multiple doctors repeatedly reverted to trying simultaneously, often with suboptimal equipment. This wasn’t due to lack of skill – objectively, the most appropriate people were trying – but to stress, cognitive load and unclear role boundaries.
It’s something that we see often in emergency situations. Under stress, individuals can become fixated on a task because of the cognitive overload and stress of the emergency. Focusing on getting IV access is easier than trying to take in the whole scenario.
I had to repeatedly reassert the plan. This felt uncomfortable, but was necessary for patient safety.
Learning
Agreeing a plan once is not enough. Under stress, teams drift. Leaders must restate, re-anchor, and re-confirm roles – kindly, but firmly.
The Trap: Task Fixation.
Multiple doctors trying the same cannula. Duplication of effort due to stress and unclear boundaries
The Fix: Re-anchor Often.
Agreeing once isn’t enough. Leaders must restate and re-confirm roles when the team drifts.
Pitfall 3: Crowding kills clarity
The resus area was noisy and crowded, with two teams effectively running in parallel. Well-intentioned help became a source of distraction.
Few people are ever involved in neonatal and paediatric emergencies; bystanders often drift across to observe. This is acceptable most of the time. However, non-essential staff can unfortunately crowd the resuscitation, adding pressure and cognitive burden on the staff performing it.
I deliberately reduced crowding, asking non-essential staff to step back and prioritising neonatal-trained staff at the bedside. This was not universally accepted. I consciously did not escalate one refusal, as airway care was safe and conflict at that moment risked further harm.
Learning
Crowding is not benign. Fewer people, clearer roles and quieter spaces improve performance — especially for procedures requiring precision.
The Trap: Crowding Kills Clarity.
Too many well-intentioned helpers increase noise and distraction.
The Fix: Control the Space.
Crowding is not benign. Politely ask non-essential staff to step back. Silence improves precision.
Pitfall 4: Plans that aren’t heard aren’t plans
Despite agreed decisions, actions repeatedly diverged. Ultrasound was discussed but not viable. Attempts continued. Noise levels rose. Situational awareness fell.
When actions diverge, team members get hyperfixated, or the environment starts to feel overwhelming; pausing is always a good option. 10 seconds to reset and reinstate the roles and goals is never wasted. It reduces the time the resuscitation team wastes repeating failed actions or forgetting key procedures.
At this point, escalation was required.
Calmly but audibly, I paused proceedings, summarised the case aloud and restated the plan. I did this not only for the team, but deliberately for the mother, who was present throughout.
Later, escalation was required again to reset the plan for NG access, respiratory support and contingency antibiotics.
Learning
Sometimes escalation isn’t about authority — it’s about resetting the room. A clear pause and summary can be one of the most powerful patient-safety tools we have.
The Trap: Unheard Plans.
Decisions were made but not followed. Situational awareness dropped as noise rose.
The Fix: The “Reset” Pause.
Escalation isn’t just about authority. Stop proceedings, summarise the case aloud, and reset the room.
Pitfall 5: Parents are not bystanders
Early in the resus, no one had spoken to the mother. Her distress was visible and growing.
It’s very easy to forget about family members as we are all fixated on the patient, and rightly so. That said, the stress on this child’s parent is at the back of everyone’s mind. This adds to the internalised pressure of the situation and, once again, contributes to cognitive overload that may lead to errors and delays.
Once roles allowed, I explained the situation, acknowledged her anxiety and ensured a staff member remained with her. This visibly changed the atmosphere – for her and for the team.
Learning
Parents are part of the environment. Ignoring them increases distress, noise and cognitive load. Including them improves care.
The Trap: Forgetting about the Family.
Mother was ignored, increasing her distress and the room’s tension.
The Fix: Include Them.
Parents are part of the environment. Acknowledging them reduces cognitive load for everyone.
Pitfall 6: No debrief, no closure
Ultimately, the team agreed the baby would be better managed in NICU, where the environment and resources were more appropriate. The transfer occurred safely.
There was no opportunity for a formal debrief. Competing clinical pressures took precedence.
Hot debriefing is recommended by national and international resus guidelines for good reason.
It allows team members to voice concerns, frustrations and, importantly, the positives of a resuscitation. By missing debriefs, team members lose valuable opportunities to reflect on what can be a very traumatic experience. RCEM Learning has an excellent blog post about debriefing and its impact on the clinicians involved.
Later feedback suggested my communication had felt “condescending”. This was uncomfortable but valuable. I followed up with A&E staff to check wellbeing and invite reflection. I couldn’t do the same with NICU colleagues.
Learning
Debriefs matter – not just for learning, but for relationships. When they don’t happen, misunderstandings persist.
The Trap: No Debrief
Transfer happened safely, but no debrief occurred. Misunderstandings about “tone” persisted.
The Fix: Debrief for Relationships.
Debriefs aren’t just for clinical learning; they are for team cohesion and reflection.
Big lessons for tiny patients
Name a leader early, especially in unfamiliar spaces
Agree roles clearly — and restate them often
One task, one pair of hands
Reduce noise and crowding proactively
Pause and summarise when things drift
Include parents as part of the care environment
Debrief whenever possible — even briefly
Neonatal emergencies don’t forgive chaos. Tiny patients rely on our ability to manage ourselves, our teams and our environments as much as our technical skill.
Sometimes the biggest pitfall isn’t the cannula you can’t get – it’s the plan no one is truly following.
