The National Academy of Medicine (formerly the Institute of Medicine) has espoused the values of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity to optimize the quality of patient care. Simulation can be integrated into proactive processes designed to improve each of these goals. Areas appropriate for integration of simulation include failure modes and effects analysis (FMEA),18 probabilistic risk assessment (PRA), responses to adverse event concerns, or other methods used to anticipate, identify, and mitigate hazards and prioritize interventions.
Clinical providers are often aware of hazards that could affect patients or themselves and many develop workarounds or protocol deviations to compensate and protect their patients or themselves. For various reasons, these hazards are not always reported, and sometimes the compensatory activities become so normalized that they are not even recognized as adaptive responses to perceived problems.
Simulations that involve care providers in their usual roles can identify bottlenecks and activities that require clarification, modification, or additional resources. For example, simulations involving trauma and blood bank personnel can be designed to focus on the processes involved in the initiation and response to activation of a massive transfusion protocol, including identifying barriers to rapid requisitioning and facilitators for prompt delivery of blood products.
Large-scale simulations, such as mass casualty simulations, may include a “table top” component that incorporates small physical objects representing patients, providers, equipment, and other resources being moved around a map of the healthcare delivery facility. Even routine patient care processes can be studied, and improving common processes may have greater cumulative positive impact on healthcare delivery than preparing for rare events.
Simulation, accompanied by skilled debriefing and integrated into improvement cycles, can provide information that can be used to surface recognition of compensatory activities, unmask hazards. assess potential solutions, inform revisions, and retest potential solutions.
Many organizations conduct emergency response simulations. These may be announced in advance, depending on the purpose of the simulation. The boundary of participation in the simulation can also vary. Some emergency response simulations involve only the local care unit, while some may integrate a broader range of potential respondents, such as the blood bank or the pharmacy. Some, such as mass casualty drills, may extend beyond the healthcare delivery organization. The breadth of involvement is determined by the purpose of the simulation.20
Simulation-Based Training for Emergency Responses by Practitioners in an Ambulatory Care Setting
After an actual event, a practitioner reported their appreciation for simulation’s ability to prepare them for emergency responses: “Today we had quite a serious medical emergency and one of my medical assistants thanked me for the mock code experience. Patient …was having an anaphylactic reaction… [we] knew what to do with the epi because of that drill.”20
The scale and scope of the simulation should reflect the scale and scope of the questions and systems being addressed. These may range from a few people participating in a very discrete, specialized process to multiagency simulations of mass casualty events or full-scale simulations of floorplans and activities before building multimillion-dollar healthcare facilities.21,22 All care processes, from rare to routine, are candidates for simulation-based activities, depending on the questions that need to be answered.
