David M. Gaba

Deepening the Theoretical Foundations of Patient Simulation as Social Practice

Simulation is a complex social endeavor, in which human beings interact with each other, a simulator, and other technical devices. The goal-oriented use for education, training, and research depends on an improved conceptual clarity about simulation realism and related terms. The article introduces concepts into medical simulation that help to clarify potential problems during simulation and foster its goal-oriented use. The three modes of thinking about reality by Uwe Laucken help in differentiating different aspects of simulation realism (physical, semantical, phenomenal). Erving Goffmans concepts of primary frames and modulations allow for analyzing relationships between clinical cases and simulation scenarios. The as-if concept by Hans Vaihinger further qualifies the differences between both clinical and simulators settings and what is important when helping participants engage in simulation. These concepts help to take the social character of simulation into account when designing and conducting scenarios. The concepts allow for improved matching of simulation realism with desired outcomes. It is not uniformly the case that more (physical) realism means better attainment of educational goals. Although the article concentrates on mannequin-based simulations that try to recreate clinical cases to address issues of crisis resource management, the concepts also apply or can be adapted to other forms of immersive or simulation techniques.

The future vision of simulation in health care

Simulation is a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. The diverse applications of simulation in health care can be categorised by 11 dimensions: aims and purposes of the simulation activity; unit of participation; experience level of participants; health care domain; professional discipline of participants; type of knowledge, skill, attitudes, or behaviours addressed; the simulated patient’s age; technology applicable or required; site of simulation; extent of direct participation; and method of feedback used. Using simulation to improve safety will require full integration of its applications into the routine structures and practices of health care. The costs and benefits of simulation are difficult to determine, especially for the most challenging applications, where long term use may be required. Various driving forces and implementation mechanisms can be expected to propel simulation forward, including professional societies, liability insurers, health care payers, and ultimately the public. The future of simulation in health care depends on the commitment and ingenuity of the health care simulation community to see that improved patient safety using this tool becomes a reality.

The Role of Debriefing in Simulation-Based Learning

The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic

Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience

Several gaps exist in the training of clinicians in health care domains, such as anesthesiology, that have the cognitive profile of complexity and dynamism. These features are shared with other industries such as commercial aviation. Training for cockpit crews on Crew Resource Management (CRM) emphasizes decision-making and teamwork principles. The authors created a simulation-based curriculum (ACRM) for anesthesiology based on principles of CRM in aviation. The training philosophy adapted to health care is one of training single-discipline crews to work in teams. The ACRM curriculum involves highly realistic simulation scenarios requiring complex decision making and interaction with multiple personnel. Scenarios are each followed by a detailed debriefing using videotapes of the simulation session. ACRM has been adopted at major health care institutions around the world. Special training for instructors is provided, especially concerning debriefing. The ACRM approach has been extended to a wide variety of other health care domains that involve complexity and dynamism, such as emergency and trauma medicine, intensive care, and cardiac arrest response teams. Simulation-based training based on CRM principles is expected to become routine in many health care settings in the coming decade.

The culture of safety: results of an organization-wide survey in 15 California hospitals

Objective: To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status. Design: Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings. Setting: 15 hospitals participating in the California Patient Safety Consortium. Subjects: A sample of 6312 employees generally comprising all the hospital’s attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response. Main outcome measures: Frequency of responses suggesting an absence of safety culture (“problematic responses” to survey questions) and the frequency of “neutral” responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status. Results: The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers. Conclusion: Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

Anaesthesiology as a model for patient safety in health care

Although anaesthesiologists make up only about 5% of physicians in the United States, anaesthesiology is acknowledged as the leading medical specialty in addressing issues of patient safety.1 Why is this so? Firstly, as anaesthesia care became more complex and technological and expanded to include intensive care it attracted a higher calibre of staff. Clinicians working in anaesthesiology tend to be risk averse and interested in patient safety because anaesthesia can be dangerous but has no therapeutic benefit of its own. Anaesthesiology also attracted individuals with backgrounds in engineering to work either as clinicians or biomedical engineers involved in operating room activities. They and others found models for safety in anaesthesia in other hazardous technological pursuits, including aviation. 2 3 Secondly, in the 1970s and ‘80s the cost of malpractice insurance for anaesthesiologists in the United States soared and was at risk of becoming unavailable. The malpractice crisis galvanised the profession at all levels, including grass roots clinicians, to address seriously issues of patient safety. Thirdly, and perhaps most crucially, strong leaders emerged who were willing to admit that patient safety was imperfect and that, like any other medical problem, patient safety could be studied and interventions planned to achieve better outcomes. #### Summary points Anaesthesiology is acknowledged as the leading medical specialty in addressing patient safety Anaesthesia is safer than ever owing to many different types of solutions to safety problems Solution strategies have included incorporating new technologies, standards, and guidelines, and addressing problems relating to human factors and systems issues The multidisciplinary Anesthesia Safety Foundation was a key vehicle for promoting patient safety A crucial step was institutionalising patient safety as a topic of professional concern Although anaesthesiology has made important strides in improving patient safety, there is still a long way to go ### Anaesthesia: safer than ever It is widely believed that anaesthesia is …

Relationship of Safety Climate and Safety Performance in Hospitals

OBJECTIVE To examine the relationship between measures of hospital safety climate and hospital performance on selected Patient Safety Indicators (PSIs). DATA SOURCES Primary data from a 2004 survey of hospital personnel. Secondary data from the 2005 Medicare Provider Analysis and Review File and 2004 American Hospital Associations Annual Survey of Hospitals. STUDY DESIGN A cross-sectional study of 91 hospitals. DATA COLLECTION Negative binomial regressions used an unweighted, risk-adjusted PSI composite as dependent variable and safety climate scores and controls as independent variables. Some specifications included interpersonal, work unit, and organizational safety climate dimensions. Others included separate measures for senior managers and frontline personnels safety climate perceptions. PRINCIPAL FINDINGS Hospitals with better safety climate overall had lower relative incidence of PSIs, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame. Frontline personnels perceptions of better safety climate predicted lower risk of experiencing PSIs, but senior manager perceptions did not. CONCLUSIONS The results link hospital safety climate to indicators of potential safety events. Some aspects of safety climate are more closely related to safety events than others. Perceptions about safety climate among some groups, such as frontline staff, are more closely related than perceptions in other groups.

Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment.

Objectives. Acquisition and maintenance of the skills necessary for successful resuscitation of the neonate are typically accomplished by a combination of completion of standardized training courses using textbooks, videotape, and manikins together with active participation in the resuscitation of human neonates in the real delivery room. We developed a simulation-based training program in neonatal resuscitation (NeoSim) to bridge the gap between textbook and real life and to assess trainee satisfaction with the elements of this program. Methods. Thirty-eight subjects (physicians and nurses) participated in 1 of 9 full-day NeoSim programs combining didactic instruction with active, hands-on participation in intensive scenarios involving life-like neonatal and maternal manikins and real medical equipment. Subjects were asked to complete an extensive evaluation of all elements of the program on its conclusion. Results. The subjects expressed high levels of satisfaction with nearly all aspects of this novel program. Responses to open-ended questions were especially enthusiastic in describing the realistic nature of simulation-based training. The major limitation of the program was the lack of fidelity of the neonatal manikin to a human neonate. Conclusion. Realistic simulation-based training in neonatal resuscitation is possible using current technology, is well received by trainees, and offers benefits not inherent in traditional paradigms of medical education.

Situation Awareness in Anesthesiology

Situation awareness has primarily been confined to the aviation field. We believe that situation awareness is an equally important characteristic in the complex, dynamic, and risky field of anesthesiology. We describe three aspects of situations of which the decision maker must remain aware: subtle cues, evolving situations, and special knowledge elements. We provide examples of real or simulated anesthesia situations in which situation awareness is clearly involved in the provision of optimal patient care, and we map the elements of situation awareness onto a cognitive process model of the anesthesiologist. Finally, we consider how situation awareness can be further investigated and taught in this medical domain using anesthesia simulators and analyses of real cases. The study of situation awareness in anesthesiology may provide a good example of the wider application of the concept of situation awareness to nonaerospace environments.

The future vision of simulation in healthcare.

Simulation is a technique-not a technology-to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. The diverse applications of simulation in healthcare can be categorized by 11 dimensions: aims and purposes of the simulation activity; unit of participation; experience level of participants; healthcare domain; professional discipline of participants; type of knowledge, skill, attitudes, or behaviors addressed; the simulated patients age; technology applicable or required; site of simulation; extent of direct participation; and method of feedback used. Using simulation to improve safety will require full integration of its applications into the routine structures and practices of healthcare. The costs and benefits of simulation are difficult to determine, especially for the most challenging applications, where long-term use may be required. Various driving forces and implementation mechanisms can be expected to propel simulation forward, including professional societies, liability insurers, healthcare payers, and ultimately the public. The future of simulation in healthcare depends on the commitment and ingenuity of the healthcare simulation community to see that improved patient safety using this tool becomes a reality.