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Simulation and Integration Into Patient Safety Systems

Phrampus, Paul E. MD, FACEP, FSSH, CPPS

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: August 2018 - Volume 13 - Issue 4 - p 225-226
doi: 10.1097/SIH.0000000000000332
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Given the current global pressures to increase the quality and improve the safety of healthcare while reducing costs, one could argue that there is a perfect storm afoot to increase significantly the use of simulation in direct support of these goals. Simulation has the potential to play an increased role in improving quality and patient safety through a deeper understanding of potential capabilities, and integration into the healthcare efforts that oversee such endeavors inside of hospitals and healthcare systems. In the current issue of Simulation in Healthcare, Macrae,1 an improvement scientist with experience in safety in other high reliability industries, suggests how healthcare simulation can be used in several ways and to positive effect to improve patient safety at the system level.

In 2000, the Institute of Medicine report entitled, “To Err Is Human,” that launched the modern era of patient safety mentions simulation 18 times as a key strategy to improve the safety of patients.2 Despite this, there has not been widespread systematic, consistent adoption of simulation into the patient safety efforts of hospitals and health systems. This is not to say that quality efforts do not exist. One could argue that simulation has not been rolled out in a consistent, systematic way that could leverage its full potential. Such potential could be realized through integration that includes a deliberate alignment along with establishing new relationships with those who are ultimately responsible to drive such improvements.

In addition to the ethical and moral implications of delivering the highest quality of care, there are significant financial reasons for doing so. Whereas the human suffering associated with harm through errors in healthcare delivery is tragic, it is also clear that errors increase the cost of care dramatically. For the last decade, in many parts of the world, there have been various government and payor programs that financially penalize hospitals and care facilities for patient care errors. Such financial pressures coupled with increasing transparency associated with publicly reported quality data are creating a climate that is ripe for the introduction of simulation to be more fully appreciated as an important part of quality improvement efforts and safety programs. It is likely that decision makers will be more receptive to incorporating simulation to help achieve their goals if the value of the approach can be tangibly demonstrated.

Simulation efforts today span a breadth of utilization across multiple domains of healthcare and serve the needs of many different constituents for a variety of purposes. For the last several decades, many programs and initiatives are often described as being part of or solely focused on patient safety initiatives. Many programs across the healthcare professions are using simulation to educate and train people and teams on curricula that are deemed important to their local mission.

A number of efforts describe a focus on specific skills or conditions of known high-risk areas as well as teamwork and communications. There has been a student or provider focused implementation of simulation that has provided important and often intense learning opportunities for individuals and teams of caregivers. Although the education of topics of clinical safety concern is an important endeavor, they are only a small part of the overall goals and needs of an organizational patient safety program.

Although uncommon, some authors have described successful utilization of simulation as a system probing tool to uncover latent threats to patient safety.3,4 Simulation has also been successfully implemented to provide evaluations of process, environmental design, equipment usability, and systems responses to assist in improvement strategies associated with the provision of care.5–7 However, rarely is there a demonstration of deep integration at a system level that appreciates the full capabilities of simulation into patient safety efforts. Despite descriptions of systems implementation of simulation for patient safety improvement efforts in the literature dating for more than 20 years, there still is a relative paucity of systematic, widespread adoption of it for this purpose in a fully integrated way.

Simulation should play an important role in augmenting the ability of care systems to fully understand errors and near misses and be an integral part of the discovery, implementation, and sustainment of solutions to avoid them in the future. These are important components of improvement to help the healthcare industry transform itself into a high reliability industry as described by the Agency for Healthcare Research and Quality.8

Understanding the breadth of safety operations at a comprehensive, systems level and then carefully matching it with the capabilities and advantages of simulation can lead to increased success in furthering integration. In 2007, Gaba9 noted that “Using simulation to improve safety will require full integration of its applications into the routine structures and practices of healthcare.”

To move these efforts forward simulation programs will need to establish new relationships and understanding of safety at the systems level to catalyze adoption efforts. We previously described the importance of pre-existing relationships between simulation programs and other senior leaders in areas such as safety, quality, and risk, as a successful strategy to allow simulation programs to be integral to leading the development of patient and care provider safety solutions.10

The Society for Simulation in Healthcare recognized the importance of having simulation further embedded into healthcare systems during the development of its comprehensive accreditation program. The systems integration focus area of the current accreditation program outlines criteria that a program seeking such recognition must demonstrate.11 This includes demonstrating the presence of a deep working relationship with the quality, risk, and safety leadership of the affiliated healthcare organization. Programs applying for this recognition must demonstrate bidirectional communications between safety and quality leadership teams of the hospital and the simulation program specifically to identify and create solutions that include simulation. Such program criteria focus attention on the importance of forming and maintaining critical external relationships.

Although the title of work by Macrae1 seems to suggest a focus on investigation of accidents, the article is proposing a broader and more in-depth strategy to implement simulation efforts into patient safety systems. He points out some of the nuances of safety expertise and how experts in this area approach error investigation, learning, and mitigation. Perhaps interprofessional education between healthcare simulation experts, clinicians, and safety system experts could further uncover how our craft could further improve healthcare. One area of potential synergy outlined in this article is focusing on the training of incident investigators and the critical thinking associated with identifying the underlying true causes of errors and near misses.

Macrae1 goes on to suggest five areas of potential engagement strategies to promote deeper integration of simulation programs with safety systems associated with healthcare delivery. He then proposes how simulation might help achieve enhanced effectiveness to accomplishing such program goals. Overall, the article introduces a framework for further implementation of simulation into an organizational safety program. It also serves as a point of reference for further dialog on such implementation strategies.

Pursuing a deeper level of simulation integration with patient safety systems is an important pathway for the simulation community. Partnering with the quality and safety experts of affiliated systems will catalyze deeper involvement with and shared learning with respect to existing problems and simulation opportunities. These partnering efforts will help further unlock the currently underrecognized value of embedding simulation more deeply into the quality and safety efforts of the healthcare system. This in turn will help bolster the partnerships and provide more evidence of the return on investment associated with simulation while simultaneously addressing the underlying moral and ethical imperative to improve the safety of healthcare.


1. Macrae C. Imitating incidents: how simulation can improve safety investigation and learning from adverse events. Simul Healthc 2018. DOI:10.1097/SIH.0000000000000315.
2. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000:287.
3. Barbeito A, Bonifacio A, Holtschneider M, et al. In situ simulated cardiac arrest exercises to detect system vulnerabilities. Simul Healthc 2015;10(3):154–162.
4. Patterson MD, Geis GL, Falcone RA, et al. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf 2013;22(6):468–477.
5. Dieckmann P, Clemmensen MH, Sørensen TK, et al. Identifying facilitators and barriers for patient safety in a medicine label design system using patient simulation and interviews. J Patient Saf 2016;12(4):210–222.
6. Kobayashi L, Parchuri R, Gardiner FG, et al. Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias. BMJ Qual Saf 2013;22(1):72–83.
7. Pati D, Evans J, Waggener L, et al. An exploratory examination of medical gas booms versus traditional headwalls in intensive care unit design. Crit Care Nurs Q 2008;31(4):340–356.
8. AHRQ A.f.H.R.a.Q. Available at: Accessed May 2, 2018.
9. Gaba DM. The future vision of simulation in healthcare. Simul Healthc 2007;2(2):126–135.
10. Phrampus PE, O'Donnell JM, Farkas D, et al. Rapid development and deployment of Ebola readiness training across an academic health system: the critical role of simulation education, consulting, and systems integration. Simul Healthc 2016;11(2):82–88.
11. Society for Simulation in Healthcare. Acceditation 2017. Available at: Accessed March 15, 2017.
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