In situ simulation: Identification of systems issues

doi:10.1053/j.semperi.2013.02.007

Seminars in Perinatology

Volume 37, Issue 3, June 2013, Pages 161-165

https://doi.org/10.1053/j.semperi.2013.02.007 Get rights and content

Abstract

The Institute of Medicine's report, To Err is Human, concluded that “medical errors are not a result of isolated individual actions but rather faulty systems, processes, and conditions that lead people to make mistakes.” In situ simulation offers the unique opportunity to train the teams of people who deliver healthcare while enhancing policies, evaluating new technologies, and improving the systems that support the delivery of safe healthcare. For this reason, the Institute of Medicine, the Joint Commission, and the Agency for Healthcare Research and Quality recommend medical simulation as one of the most important safe practice interventions to reduce errors and risks associated with the process of care. This review builds on other reports in this issue and discusses the application of in situ simulation to identify, address, and test systems improvements.

Introduction

Every system is perfectly designed to get the results it gets.
Paul Batalden

More than 75 infants die each day in the United States. According to the Joint Commission (JC), two-thirds of sentinel events (cases of neonatal death or permanent disability) during childbirth are attributable to preventable failures in communication, staff competency, and other systems factors.1, 2, 3 The Institute of Medicine's (IOM) report, To Err is Human, concluded that “medical errors are not a result of isolated individual actions but rather faulty systems, processes, and conditions that lead people to make mistakes.”⁴ The process of evaluating teams of people who deliver healthcare and of researching the effectiveness of technologies and human-technology interactions while examining the interface of policies, guidelines, and clinical judgment is difficult—in situ simulation offers the valuable opportunity to potentially evaluate all simultaneously. For this reason, the IOM, the JC, and the Agency for Healthcare Research and Quality (AHRQ) recommend medical simulation as one of the most important safe practice interventions to reduce errors and risks associated with the process of care.⁵ This review builds on other reports in this issue and discusses the application of in situ simulation to identify, address, and test systems improvements.

Section snippets

What is in situ simulation?

According to Webster's dictionary, in situ means “in the natural or original position or place” with the Latin origin meaning “in position.”⁶ However, in situ simulation goes beyond simply physically locating simulators in the clinical environment. In situ simulation at its best involves simulation that accounts for and is fully integrated with clinical operations, people, information, technology, and systems.

In situ simulation is based upon the aviation industry's experience with simulation

Rationale

Several factors make in situ simulation an advantageous format for learning:

Educational fidelity supports adult learning theory. In situ simulation supports learning skills in the environment where learners are expected to apply them. Not only does this environment support Kolb and Fry's adult learning theory,¹⁰ creating an activated learner by demonstrating the clinical relevance of the new skill, it also enables the learner to understand how to utilize all human and technological resources to

What is required to conduct in situ simulation?

As detailed in a prior publication, high-fidelity in situ simulation requires consideration of several aspects of the local environment.²¹ For example, understanding the local team structure and care processes in the design of the simulation helps the simulation retain sufficient realism and meaning. In obstetrics, these considerations might include how many and what types of professionals attend vaginal and cesarean births; who is called in cases of emergency (emergency medicine physician,

Healthcare, systems issues, and in situ simulation

Healthcare is a complex system involving workers, the workplace (including technology, equipment, and physical environment), work processes, and the people who benefit from the work. The system has multiple layers of defenses that prevent errors. As James Reason points out, healthcare is a human activity, humans are fallible, and they should be expected to make errors in any system.²² He conceptualized that a healthcare system has multiple layers of defenses against human errors like layers or

Evidence that in situ simulation is effective

We have found that in situ simulation is effective at detecting systems issues regardless of the size or nature of the clinical system. We conducted a multi-center single-arm intervention study to test whether in situ simulation of obstetric emergencies and teamwork training improved the process of care and patient safety across geographically, organizationally, and clinically diverse hospital settings. Hospitals were purposively sampled for geographic, clinical, and organizational diversity,

Conclusions

In summary, in situ simulation is an effective way to develop new skills, to maintain infrequently used clinical skills even among experienced clinical teams, and to uncover and address latent safety threats in the clinical setting. The advantages of in situ training may include cost reductions for education, increased access for a greater number of staff, and ability to address issues specific to the institution and the site of practice. While it is impossible to expect the perfect system, our

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Implications of Crew Resource Management Training for Tank Crews
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Effects of Crew Coordination Training and Evaluation Methods on AH-64 Attack Helicopter Battalion Crew Performance
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Cited by (43)

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology
2023, Journal of Obstetrics and Gynaecology Canada
To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.
Providers working to improve health care for Canadian women and their families; patients and their families.
Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.
This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.
Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords “simulation” and “simulator.” The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).
All health care professionals working to improve Canadian women’s health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.
- 1.
  Health care professionals in obstetrics and gynaecology should understand the value of both in situ and off-site simulation as a tool for education, patient safety, and quality improvement at both the team and individual levels (strong, moderate).
- 2.
  Health care professionals in obstetrics and gynaecology should be aware of the overall cost reduction associated with the use of simulation (strong, moderate).
- 3.
  Stakeholders at all levels must commit to an ongoing simulation program, including identifying, training, and supporting simulation advocates, as well as securing adequate funding. This approach leads not only to organizational readiness but also to quality improvement and positive culture change (strong, moderate).
- 4.
  Providers of obstetrical and gynaecological care should be familiar with key simulation modalities and principles of how to advance knowledge using simulation (conditional, low).
- 5.
  Purposeful simulation activities must be based on local needs assessments and knowledge gaps (conditional, low).
- 6.
  Interprofessional/interdisciplinary teams should participate in the design, implementation, and evaluation of team training and in situ simulation programs (strong, high).
- 7.
  Debriefing must be promoted as a fundamental component of the experiential learning process. Team debriefing/peer debriefing with a written guide can be as effective (as an alternative) as expert debriefing (strong, high).
- 8.
  Psychological safety must be established for all personnel within the simulation and the debriefing (strong, moderate).
- 9.
  Program evaluation, a system to measure the efficacy of a learning activity, must be included in the planning of simulation activities to assess whether the targeted outcomes of the program were achieved (strong, moderate).
- 10.
  Simulation-based activities should be designed in a culturally sensitive and socially responsible way, similar to all other aspects of health professionals’ education (strong, low).
Déclaration de consensus n<sup>o</sup> 434: Simulation en obstétrique et gynécologie
2023, Journal of Obstetrics and Gynaecology Canada
Donner une vue d’ensemble détaillée et à jour des données probantes sur la valeur de la simulation dans l’enseignement, la formation en équipe, la sécurité des patientes et l’amélioration de la qualité en obstétrique et gynécologie afin de bien faire connaître les principes à prendre en compte dans l’élaboration d’un programme de simulation et de fournir des outils et références pour les ambassadeurs de la simulation.
Les fournisseurs de soins qui travaillent à améliorer les soins de santé pour les Canadiennes et leurs familles; les patientes et leur famille.
La simulation est un mode de formation reconnu dans la littérature pour sa contribution aux résultats positifs relativement à l’atteinte des objectifs d’apprentissage, au maintien des compétences individuelles et d’équipe et à l’amélioration de la sécurité des patientes. La simulation est un mode de formation très développé qui suit des principes établis pour maximiser son utilité et créer un environnement sécurisant pour les participants. La simulation est le plus efficace lorsqu’elle implique la collaboration interprofessionnelle, le soutien institutionnel et la répétition régulière.
Ce mode de formation contribue à parfaire les compétences en travail d’équipe, à améliorer les issues des patientes et à optimiser les dépenses pour le système de santé. Lors de la mise en œuvre d’un programme de simulation, le respect des principes prescrits concernant la sécurité psychologique réduit au minimum le risque de préjudice pour les participants. Cependant, la simulation peut être un outil coûteux qui exige des ressources humaines, des ressources matérielles et du temps.
Des recherches ont été faites dans les bases de données Medline et PubMed à partir des mots clés simulation et simulator pour recenser les articles publiés entre 2003 et 2022. La recherche s’est limitée aux articles publiés en anglais et en français. Le groupe de travail de la SOGC sur la simulation a examiné les articles pour en déterminer la qualité, la pertinence et la valeur. Les opinions d’experts tirées de livres de référence pertinents ont aussi été prises en compte.
Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l’annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et conditionnelles [faibles]).
Tous les professionnels de la santé qui travaillent à améliorer la santé des Canadiennes et tous les intervenants pertinents, y compris : organismes subventionnaires; collèges de médecins; ordres des infirmiers et infirmières et des sages-femmes; organismes d’agrément; centres universitaires; hôpitaux; et programmes de formation.
- 1.
  Les professionnels de la santé en obstétrique et gynécologie doivent comprendre l’utilité de la simulation in situ et hors site comme outil de formation, d’assurance de la sécurité des patientes et d’amélioration de la qualité, tant pour l’équipe que pour chacun de ses membres (forte, moyenne).
- 2.
  Les professionnels de la santé en obstétrique et gynécologie doivent avoir conscience de la réduction globale des coûts découlant du recours à la simulation (forte, moyenne).
- 3.
  Les intervenants à tous les niveaux doivent s’engager à offrir un programme de simulation permanent, notamment en nommant, formant et soutenant les ambassadeurs de la simulation ainsi qu’en obtenant le financement nécessaire. Cette approche permet à l’organisation de se parer à toute éventualité, mais aussi d’améliorer la qualité et d’adopter un changement de culture positif (forte, moyenne).
- 4.
  Les fournisseurs de soins obstétricaux ou gynécologiques doivent connaître les principaux modes de simulation et les principes d’apprentissage par simulation (conditionnelle, faible).
- 5.
  Pour être utiles, les activités de simulation doivent reposer sur l’évaluation des besoins locaux et sur les manques de connaissances (conditionnelle, faible).
- 6.
  Les équipes interprofessionnelles et interdisciplinaires doivent participer à la conception, à la mise en œuvre et à l’évaluation des programmes de formation d’équipe et de simulation in situ (forte, élevée).
- 7.
  Le débreffage doit être encouragé et vu comme un élément fondamental du processus d’apprentissage expérientiel. Le débreffage d’équipe ou entre pairs au moyen d’un guide textuel peut être aussi efficace (comme solution de rechange) que le débreffage par un expert (forte, élevée).
- 8.
  La sécurité psychologique doit être établie pour chaque membre du personnel participant à la simulation et au débreffage (forte, moyenne).
- 9.
  L’évaluation du programme par un système mesurant l’efficacité de l’activité d’apprentissage doit faire partie de la planification des activités de simulation afin de pouvoir déterminer si les résultats ciblés du programme ont été atteints (forte, moyenne).
- 10.
  Les activités de simulation doivent être socialement responsables et conçues avec attention aux besoins culturels, comme pour tous les autres aspects de la formation des professionnels de la santé (forte, faible).
Alternatives to High-Fidelity Simulation
2020, Anesthesiology Clinics
Cognitive Aids in the Management of Critical Events
2020, Anesthesiology Clinics
Readiness: Utilizing bundles and simulation
2019, Seminars in Perinatology
Citation Excerpt :
Simulation can be in situ—meaning on the labor unit itself—or in a simulation center. Simulation in situ offers the opportunity to train providers in the environment in which they will actually be facing an emergency, allowing for identification of systems-related issues so they can be remedied.30 In situ simulation supports the principle that adults learn better in their usual clinical environment.
Postpartum hemorrhage is an important contributor to maternal morbidity, and is one of the most common worldwide causes of preventable maternal mortality. Preventing significant morbidity and mortality from postpartum hemorrhage necessitates preparedness on both a unit and patient level. Our objectives are to define a bundle, to review the elements of the Council on Patient Safety in Women's Healthcare Obstetric Hemorrhage Bundle and to highlight simulation-based training opportunities, focusing on readiness for this significant obstetric emergency.
Simulation for critical care
2019, Clinical Simulation: Education, Operations and Engineering
Simulation is now well established as a teaching modality in critical care. It has emerged as an answer to increasing concerns about medical errors and patient safety. Simulation in critical care provides many benefits: enhancing education programs at an undergraduate and postgraduate level and for continuing professional development, providing an opportunity to train as a team and improve teamwork performance, improving patient safety by ensuring competence and detecting latent safety threats, and improving technical skills. This chapter discusses the evidence supporting these benefits and briefly examines learning theories that reinforce the use of simulation in critical care medicine. It also provides the reader with examples of what is currently being done in this field.

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Seminars in Perinatology

Abstract

Introduction

Section snippets

What is in situ simulation?

Rationale

What is required to conduct in situ simulation?

Healthcare, systems issues, and in situ simulation

Evidence that in situ simulation is effective

Conclusions

References (22)

Sentinel event alert: preventing infant death and injury during delivery. Jt Comm Perspect

Adverse events detected by clinical surveillance on an obstetric service

Obstet Gynecol

Cause and effect analysis of closed claims in obstetrics and gynecology

Obstet Gynecol

To Err is Human: Building a Safer Health System

Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California at San Francisco-Stanford Evidence-based Practice Center under Contract No. 290-97-0013); AHRQ Publication No. 01-E058

Implications of Crew Resource Management Training for Tank Crews

Effects of Crew Coordination Training and Evaluation Methods on AH-64 Attack Helicopter Battalion Crew Performance

Team training in the skies: does crew resource management (CRM) training work?

Hum Factor

Toward an applied theory of experiential learning

Improving preventive care by prompting physicians

Arch Intern Med

Cited by (43)

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

Déclaration de consensus n<sup>o</sup> 434: Simulation en obstétrique et gynécologie

Alternatives to High-Fidelity Simulation

Cognitive Aids in the Management of Critical Events

Readiness: Utilizing bundles and simulation

Simulation for critical care