In situ simulation: Identification of systems issues
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
References (22)
Sentinel event alert: preventing infant death and injury during delivery. Jt Comm Perspect
(2004)- et al.
Adverse events detected by clinical surveillance on an obstetric service
Obstet Gynecol
(2006) - et al.
Cause and effect analysis of closed claims in obstetrics and gynecology
Obstet Gynecol
(2005) - et al.
To Err is Human: Building a Safer Health System
(1999) - et al.
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
(2001) - ...
Implications of Crew Resource Management Training for Tank Crews
(1996)- et al.
Effects of Crew Coordination Training and Evaluation Methods on AH-64 Attack Helicopter Battalion Crew Performance
(1993) - et al.
Team training in the skies: does crew resource management (CRM) training work?
Hum Factor
(2001) - et al.
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
2023, Journal of Obstetrics and Gynaecology CanadaDéclaration de consensus n<sup>o</sup> 434: Simulation en obstétrique et gynécologie
2023, Journal of Obstetrics and Gynaecology CanadaAlternatives to High-Fidelity Simulation
2020, Anesthesiology ClinicsCognitive Aids in the Management of Critical Events
2020, Anesthesiology ClinicsReadiness: Utilizing bundles and simulation
2019, Seminars in PerinatologyCitation 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.
Simulation for critical care
2019, Clinical Simulation: Education, Operations and Engineering