Simulation and Patient Safety – a complex relationship?

By Victoria Brazil (@SocraticEM)

Simulation enthusiasts cite patient safety as a key rationale for simulation based education, but few recognize or articulate the potential for simulation to cause harm – to participants, and even to patients. Just this afternoon I watched with trepidation as our ED nursing staff attached a live defibrillator to our simulated patient during our weekly simulation scenario.…… What if….?

The potential benefits of SBME are real – improved procedural skills, better teamwork, and identification of latent safety threats all have measurable, positive impacts on patient care – and simulation educators and researchers focus on achieving and researching these outcomes. Much less is written or discussed about harms from SBME.

The Foundation for Healthcare Simulation Safety is trying to change that. Created by Dan Raemer and Ann Mullen from the Center for Medical Simulation in Boston, their website cites examples of a diverse array of real and potential harms from simulation activities. The Foundation website provides details of incidents, many involving real and fake medication misadventure. They provide  access to labels designed to prevent those errors. Ann and Dan are also trying to use social media to promote this cause and to facilitate sharing stories of adverse events in sim and best practices in preventing them. Check out #keepsimsafe on Instagram and Twitter, and listen to recent podcasts on this topic at Simulcast and DJ Simulationistas.

Threats to learner psychological safety, and suggested mitigation strategies, are often discussed.  However there are diverse categories of risk inherent in simulation, including patient and institutional risks from fake medications and/or equipment, classic occupational health and safety risks from sharps, electrical equipment and cables, or unintended triggering of hospital responses to simulation activities. Frameworks and practical strategies have been offered for prospectively identifying and mitigating these risks. [1,2]

This issue also suffers from being at the ‘unsexy’ end of sim. Similar to consumables inventory or mannikin maintenance schedules, developing policies and procedures to reduce safety risks is tedious work compared to the fun of running a scenario. And yet it has the potential to bring down our programs in minutes with a sentinel event.

Clearly the role of safety criteria in accreditation standards for simulation programs is an important element, and these continue to evolve. They provide guidance for those developing local institutional policies and procedures.    The Society for Simulation in Healthcare (SSIH) accreditation standards include detailed safety requirements for programs, including “Mechanisms to protect and address physical and psychological safety of individuals involved in simulation, including orientation to the environment.” And “mechanisms to appropriately separate simulation and actual patient care materials (e.g. equipment, supplies, and patient information).

I think there are four actions for every simulation educator to consider to reduce the risk of harm from our programs.

  1. Raise our personal vigilance to take a 5minute ‘time out’ when planning or delivering a sim – “what could go wrong here that would threaten learner or patient safety?”.
  2. Re-think our safety processes in our local simulation programs and collaboratively develop risk management strategies (and paperwork , sigh..)
  3. Discuss safety issues in faculty development workshops or meetings, and
  4. Collect and report data – to local institutional adverse event reporting processes and/or to an (yet to be formed!) international database of adverse events in simulation.

Stay safe and simulate.


  1. Marshall, S. and McIntosh, C. (2017) Strategies for managing adverse events in healthcare simulations, in Healthcare Simulation Education: Evidence, Theory and Practice (edsD. Nestel, M. Kelly, B. Jolly and M. Watson), John Wiley & Sons, Ltd, Chichester, UK.
  2. Torrie J, Cumin D, Sheridan J, et al Fake and expired medications in simulation-based education: an underappreciated risk to patient safety BMJ Qual Saf Published Online First: 20 January 2016. doi: 10.1136/bmjqs-2015-004793

Image courtesy of Foundation for Healthcare Simulation Safety