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Fake and expired medications in simulation-based education: an underappreciated risk to patient safety
  1. Jane Torrie1,2,
  2. David Cumin1,
  3. Janie Sheridan3,
  4. Alan F Merry1,2
  1. 1Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
  2. 2Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
  3. 3School of Pharmacy, University of Auckland, Auckland, New Zealand
  1. Correspondence to Dr Jane Torrie, Department of Anaesthesiology, University of Auckland, Auckland 1071, New Zealand; j.torrie{at}

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In January 2015, the US Food and Drug Administration (FDA) reported that at least 40 patients had received non-sterile intravenous fluids, resulting in associated adverse events and one death. The offending products were produced for educational purposes by a company supplying the growing healthcare simulation market, and were not intended for patients. The plastic bags, labelled to mimic sterile 0.9% saline solution, contaminated the medication supply chain in 22 locations.1 Although the sequence of events is not yet clear, the supply shortage of 0.9% saline in the USA2 may have been a contributory factor. The presence of fake products was a latent condition or ‘resident pathogen’3 which in certain circumstances led to error and patient harm.

Harbingers of the tragic events above have been reported, such as the discovery of demonstration adrenaline syringes on an emergency trolley for clinical use and the treatment of anaphylaxis with an Epipen subsequently found to be an inactive training device.4 An editorial on unintended consequences of simulation5 highlighted administration of fake medications as a potential hazard to patients, and simulating medications has been an active topic in the simulation community, for example on the Society For Simulation in Healthcare Listserve.

Simulation-based activities are common in healthcare education and an expanding evidence base suggests they are also useful for improving patient safety6 ,7 and for detecting latent safety threats in new products.8 Debate continues on how accurately the clinical environment should be recreated to achieve educational objectives and to enable transfer of learning to the workplace.9 One approach is to use clinical areas for simulation activities (in situ) as opposed to using separate, dedicated simulation spaces.10

Medication errors are a persistent and important problem in healthcare.11 Simulation-based education in any location often incorporates medication, …

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