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of results Analysis identified weaknesses in core patient safety themes, namely exchanging information and the need for leadership. Other issues which emerged included challenging building access, outdated equipment, and lack of policy to manage other inpatients during an emergency response. Following implementation of the recommendations, improvement was noted in cardiac arrest response processes during the repeat mock codes. Discussion, conclusions and recommendations In situ high-fidelitydoi:10.1136/bmjstel-2019-aspihconf.58 fatcat:w3mlg4qrqrgnxjt2rmvec4h6by