Pa Pat Saf Advis 2016 Dec;13(4):169-171.
Can Simulation in situ Improve Patient Safety?
Anesthesiology; Critical Care; Emergency Medicine; Internal Medicine and Subspecialties; Nursing
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Ellen S Deutsch, MD, MS, FACS, FAAP, CPPS
Editor, Pennsylvania Patient Safety Advisory
Medical Director, Pennsylvania Patient Safety Authority

Senior Scientist, Children’s Hospital of Philadelphia
Adjunct Associate Professor, Perelman School of Medicine of the University of Pennsylvania


The increasing availability of simulation offers many creative opportunities to improve the capabilities of individuals, teams, and even healthcare delivery systems to improve patient safety.1-6 Simulation is “a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions.”7 Simulation can be used to create learning opportunities based on the needs of learners, at the relative convenience of the learner and the teacher, in circumstances that avoid direct risk to patients.8,9

Simulations can be conducted either in simulation centers or in situ, that is, in actual patient care locations; these different settings provide complementary opportunities. Simulation centers offer controlled conditions and provide reproducible experiences in standardized settings, but the simulations may not fully reflect the actual circumstances of patient care. Simulations conducted in situ, involving real teams, and sometimes using actual patient-care supplies and equipment, more fully represent the ways in which patient care and patient safety is impacted by the complex components of the healthcare delivery system.

Simulation in situ for Individuals

Many facilities have implemented simulation programs to enhance the skills of individuals. For example, in Pennsylvania, clinicians at the Children’s Hospital of Philadelphia (CHOP) implemented a simulation in situ program in an effort to improve the hospital’s central line–associated bloodstream infection (CLABSI) rate.10 The central venous catheter “dress rehearsal” used a utility cart with skill-trainer manikins and dressing-change supplies, which was rolled into patient care areas to provide nurses with “just in time” training (conducted before a potential dressing change) and “just in place” training (conducted at or near the patient bedside). The “train to excellence” protocol allowed cognitive and psychomotor skill testing while requiring the nurse to repeat the task until the dressing change on the manikin could be completed in full compliance with policy and procedure without needing corrective prompts. On average, the simulations were completed within 20 minutes. The program improved nurses’ knowledge, self-confidence, and psychomotor skill performance on manikins; the program was associated with improved procedural competence on real patients and temporally associated with decreased hospital CLABSI rates.

Simulation in situ for Individuals for Teams and for Healthcare Systems

Teams participating in simulation in situ—whether single specialty or inter-professional—can engage in deliberate practice of teamwork and communication skills11 and may further refine skills and processes that were feasible in a simulation center, but are more challenging in situ. Conducting simulations in situ to improve team skills almost inevitably provides opportunities to identify hazards lurking in the systems that surround, and are inextricably linked with, patient care. Simulation in situ may identify vulnerabilities in personnel and care systems, even though regulatory requirements may have been met.12,13 Simulations conducted to improve staff preparedness and evaluate operational readiness for new or renovated patient care areas have identified issues that were not readily apparent using traditional modeling and preparatory efforts,6,14 such as a finding that a moving pillar system was unstable for equipment trays and monitors.6 CHOP conducted simulations in situ prior to the separation of conjoined twins, using a model of the twins constructed from two dolls, and color coded tubing, equipment and monitors.15 The simulations allowed the peri-operative team to develop a process to maintain sterility while transferring one twin immediately post-separation to a second table in the operating room. Several facilities in the United States have conducted simulations in situ to evaluate and improve preparations for patients with Ebola. Often simulations in situ involving coordination or patient care transitions between departments provide rich information. Even simulations of routine patient-care processes conducted in situ have revealed missing or broken equipment, conflicting protocols, or difficulty accessing necessary resources. Useful information may be intentionally sought or serendipitously discovered, and may reveal hazards or help inform solutions.

It’s Not Always Easy

There are several challenges to implementing simulation in situ. Simulation experts address concerns about the potential to confuse or contaminate actual patient care equipment and medications16 by using a combination of vigilance and constraints. Some scheduling obstacles can be overcome with creativity, flexibility, sensitivity to local workload, and collaboration with local leadership.2 Somewhat ironically, cancelling a simulation because of excessive workload or shortages of equipment inherently provides information about a system’s lack of margin should any other system stress arise. Legitimate concerns about possible adverse impacts should be balanced with the potential value of improved teamwork and system safety developed through simulation in situ, and the risk of patient care hazards that may exist but are unidentified. Patterson et. al conducted a series of 90 simulations in situ in an emergency department (ED) over the course of a year, and found that, compared with simulations conducted in the simulation center, the simulations in situ identified about seven times as many latent safety threats. Identified hazards included malfunctioning equipment, knowledge gaps related to critical medications, and delayed or absent responses of vital team members.11 Simulation in situ allowed deliberate practice of teamwork and communication skills; and 71 of 73 latent safety threats identified were remedied by ED staff and leadership. The cancellation rate decreased as training matured, and about halfway through the project, ED leadership believed the training had become so valuable that they required mandatory participation.11

Impact on Patient Safety

A companion article in this issue of the Pennsylvania Patient Safety Advisory explores events related to simulations reported through the Pennsylvania Patient Safety Reporting System during the most recent 11 academic years. Simulations in situ have the potential to reveal safety hazards, as well as to provide a mechanism to elicit and test possible solutions at a systems level. Safety hazards, as well as solutions, often have applicability beyond a single patient care unit, or even a single facility. Simulations conducted in situ have the potential to enrich our understanding and management of patient safety hazards and thereby improve patient safety.


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  11. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013 Jun;22(6):468-77. Also available: PMID: 23258390.
  12. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003 Aug;78(8):783-8. PMID: 12915366.
  13. Blike GT, Christoffersen K, Cravero JP, Andeweg SK, Jensen J. A method for measuring system safety and latent errors associated with pediatric procedural sedation. Anesth Analg. 2005 Jul;101(1):48-58, table of contents. Also available: PMID:15976205.
  14. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety of new healthcare teams and new facilities. Simul Healthc. 2011 Jun;6(3):125-33. Also available: PMID:21383646.
  15. Simpao AF, Wong R, Ferrara TJ, Hedrick HL, Schwartz AJ, Snyder TL, Tharakan SJ, Bailey PD. From simulation to separation surgery: a tale of two twins. Anesthesiology. 2014 Jan;120(1):110. Also available: PMID:23503368.
  16. Raemer DB. Ignaz Semmelweis redux? Simul Healthc. 2014 Jun;9(3):153-5. Also available: PMID:24401925.

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