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mother-baby units. The five components of the program included maintaining a respite nursery, using visual management, positively framing situational communication and actions after a near-miss, safe and appropriate staffing, and celebrating and transparently displaying program successes. Data were collected on near-miss event rates and caregivers and families provided postevent comments.Results The perinatal team embraced the program at both sites. Of 9,578 live births over 1 year, 202 near-misses or good catches were documented. P