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Pneumothorax is a potentially life-threatening condition in a neonate, requiring emergency intervention. The neonatal nurse practitioner (NNP) must be able to respond quickly and competently to prevent significant potential complications or death. The purpose of this practice improvement project was to implement procedure review for NNP competency maintenance in needle thoracostomy for a tension pneumothorax and to evaluate the effectiveness of procedure review on competency through simulation performance. Eighteen NNPs participated (procedure review = 10, no review = 8). Results showed that procedure review had a small impact on total performance score. The simulation performance increased self-efficacy for all participants, and participants supported simulation-based procedural competency maintenance activities.