Simulcast Journal Club February 2019

Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field. 

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you. 
Journal Club (3)

Title :  “Dial M for Trochar 

“He’s dead.” sobbed Catherine as Nimali hugged her tightly.  The steady thumps of hail hitting the roof outside partially muffled the sound of her tears. 

“I mean, Snythe was the meanest paediatric intensivist I’d ever met, but he didn’t deserve to be stabbed through the heart with an Intercostal Catheter Trocar while acting as a Simulated Trauma Patient.”. 

Nimali winced.  “The police are going to be here any minute.  Catherine, what happened?  Tell me every detail.”. 

Catherine’s eyes glazed with painful recollection. 

“Well, we had the end of year staff meeting, everyone was here except you and Nitin, and some of the junior trainees had organised a ‘Registrar Revenge’ Simulation.  Snythe had agreed to be the Simulated Patient, and he was wearing a metal chest protector with a box of fake blood over the top of it. We were supposed to put a chest drain in, but we had just started the scenario when the power went out.  It was pitch black in the Sim room, and we were joking around.  Then we all heard a scream.” 

“When the lights came back on, Snythe was dead. And for a few seconds we laughed!  We thought it was a Sim!”. 

“Surely it was an accident?” asked Nimali.  “A horrible horrible accident.  I know Snythe had a lot of enemies, I mean, but why would you think this was murder?”. 

“The note.” Whispered Catherine in shock.  She slowly opened her clenched fist and a crumpled piece of paper unravelled.  A sentence made out of paper clippings was just visible on the inside. 

Nimali unrolled it and read the words aghast.    


Nimali shuddered.  Next month’s Quality and Safety meeting was going to be interesting. 

The Article (open access via the link) : 

Schroeder J, O’Neal C, Jagneaux T. Practically saline. J Investig Med High Impact Case Rep. 2015;3(4):2324709615618980 PMID 26663812. 


Discussion :  


While our case study has descended into a farcical murder mystery, simulation safety remains a serious and potentially deadly issue.  Scaffolding on from last month’s simulcast coverage of Raemer et al’s “Simulation Safety First : An Imperative”  we’d like to explore one of the cases referenced within that article : a case report in which 45 patients were exposed to simulated (and non sterile) saline. 

The case report is open access and well worth a read.  We hope in combination with Raemer et al’s editorial it will provide you a stimulus for reflection on Sim safety within your hospital. 


For our journal clubbers this month : 

  • What reflections does this case report prompt on your own facility’s practice? 
  • What resources and strategies have you found useful to maintain simulation safety within your own service? 


References : 

Schroeder J, O’Neal C, Jagneaux T. Practically saline. J Investig Med High Impact Case Rep. 2015;3(4):2324709615618980 PMID 26663812. 


Raemer, D., Hannenberg, A. and Mullen, A. (2018). Simulation safety first: an imperative. Advances in Simulation, 3(1). 

About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

30 thoughts on “Simulcast Journal Club February 2019

  • Ian Summers

    That is truely frightening. Thanks for putting this together and helping the earlier commentary on sim safety and the subsequent sim podcast with Vic, Dan and Kara.

    Now, one of the satisfactions of sim is when you get someone reporting back that they changed something in their clinical environment as result of your work….

    and today, writing a scenario with Lauren Sanders for an off-site stroke simulation we are running, we included for the first time a safety checklist, detailing risks of a simultaneous real clinical event during our sim, miscommunication dangers as a result, our mitigation strategies for these and those responsible for ensuring there was no leak of simulation drugs and communication and imaging from the sim world to the clinical.

    You would be pleased. Translation achieved!

    The inclusion reminded me of a sign I once saw at a building site and considered what it would look like if applied to a busy shift in the emergency department, marked as hazard and hazard reduction strategies. I will email it to you, feel free to post if you can….and I will send it out on Twitter too. Would love to know how other people write theirs and what they include…..

    Latent Safety Threats

    • Ben Symon Post author

      Thanks for coming along Ian, it’s nice to see you on the internet again :p
      I like the sign you’ve included, particularly the fact that rather than just identifying things, it identifies a solution and allocates responsibility for that solution.

  • Laura Joyce

    Thanks Team!
    We had an interesting experience recently that made me realise the importance of being aware of the wider impact of a simulation programme, as illustrated by the simulated saline case.
    We have spent a number of years building up our departmental safe container so that our in-situ (and sometimes guerrilla) simulations are ‘work as usual’ for our staff. I am so appreciative that our department has really engaged, and so the pause on seeing a mannequin that used to occur, is now almost non-existent. We just get on with it.
    However, as Simulationistas, particularly in departments with a relatively small faculty, we need to be aware how staff may start to see our roles/identities in simulation, intertwined with our clinical work.
    In the past month I have had two experiences of dragging very unwell patients out of cars at the front of the department, and having to repeatedly say to my colleagues “This is Not a Simulation, This is Not a Simulation”, as they have become used to seeing me in unexpected locations in my simulation role.
    We have tried to decrease any confusion from this type of incident by a number of methods, including facilitators always wearing large yellow stickers that say “Sim Faculty”, but I guess there is a small risk that someone will say “We don’t have time to do a sim today!”

    • Ben Symon Post author

      Hi Laura, thanks so much for joining us this month.
      Your experience of people assuming Sim Faculty are ‘faking it’ when real crises occur is familiar with me. Our excellent hospital pharmacist often helps us in a Resuscitation with infusions, but has developed a habit of checking with me if my phone call is a simulation or not before rushing to the Resus Bay.
      Interestingly just yesterday one of our SimCo’s mentioned a hospital requested mannequin defib connectors (with the metalic plates) for their real resus bay, after mistakenly believing that it is real equipment.

      I think the previous safety podcast highlighted the importance of these unintended messages we send through sim if we don’t maintain a practice consistent with real life. It’s a very tricky and interesting thing to negotiate.

      • Zachary Buxton

        The point raised in the last podcast about unintended teaching resonated with me. There are a number of things that come to mind immediately but airway positioning on QCPR infant manikins comes immediately to mind.

        Every PLS I do I stress the importance of positioning and observing for chest rise – then I have to show them an improper, unrealistic degree of extension which is followed up with “adequate” ventilation as per the feedback device without appreciable chest rise. I try to mitigate these issues but I keep thinking about the unintentional lessons being taken away from this.

        • Ben Symon Post author

          Thanks for coming along Zach!
          I think this is an important risk worth highlighting. It can be surprising what people take away.
          When I first did APLS as a junior doctor, I got the impression that muscle relaxants were somehow optional! Seems stupid in retrospect, but everytime I went to intubate I was told it went straight down! Nobody ever asked me about relaxants.

  • Susan Eller

    Hello Ben, Vic, Jesse – and anyone else I missed,

    I am so grateful that you followed up the podcast with further discussion about simulation safety. I have to admit, when the Wallcur events happened, I was working in nursing education and was not totally immersed in the simulation world. I remember hearing about it, and was glad that Dan, Janice, and others were responding and promoting simulation safety. When I came back to CISL, one of our simulation specialists – Teresa – had done a great job starting to ensure that we labeled all of our medications in the lab. Love her efforts – and those that Ian describes of developing a safety checklist.

    I think that one of the potential challenges is that we can all be very vigilant during in situ simulations in labeling our medications, fluids and devices so that they don’t harm patients. It is tempting to ease that level of scrutiny in the simulation center – too easy to think that there are greater barriers to have those simulated meds etc. actually get back to live patients. Although that is somewhat true, being lax in safety practices could still jeopardize patient safety – as per the scenario with the resident with medication in their pocket from the Raemer article. For a discipline that started from a desire to enhance patient safety, that risk is not acceptable.

    Back to Nitin and Nimali – hoping that it really is just a simulated murder mystery emphasizing simulation safety, but with those two, you never know :/.

    • Ben Symon Post author

      Hi Susan! Great to see you so soon after a few drinks at IMSH2019.
      I would confess that when I first heard about the Simulated Saline case, I kind of scoffed :
      – the error was an ordering one, not ‘the fault’ of the simulation centre
      – there was no breach of the simulated environment, somebody just made an ordering mistake.

      I’m so glad for Dan and Ann Mullen’s emphasis on this stuff, but also for the group who had the guts to write up this case study and report the details of the error.
      – It’s such an overwhelmingly confronting experience to write up such a significant error, and I wonder whether there was any reticence on the part of the team regards to the potential damage this article might cause the simulation community’s reputation, or the reputation of the department.
      – I applaud their strength as I’m sure there are many many smaller errors occurring all the time that we’re not capturing.’

      I’m wondering if anyone has a system for these problems in their hospital?

  • Eve

    Hey Ben,

    It is rare that the actual article for review keeps me as interested as your salacious intros but this month was a total exception…this despite “Dial M for Trochar” being your best writing yet 🙂

    I devoured this case report with absolute fascination and interest. Like any ‘good’ M&M there is so much contributing to the error – as the authors suggest all the way up to government level issues that contributed to the normal saline shortage in North America…I think this can lead simulation educators down a broader path to considering safety issues in a greater context that reaches much farther than the focused sim safety checklist – – for individual simulation exercises that we have started using at GCUH.

    When/if we do identify safety threats using the checklist what are factors underlying their existence – can we do a more thorough job of exploring the ‘near misses’. The most common belief I have seen is that sim educators and participants think using “fake” medications is a better idea than real medications in the sim environment. An exploration of those beliefs – not just correction of them – might lead to more enhanced understanding. There are probably any number of underlying values related to that belief – the most significant of which is cost savings for the hospital/healthcare system – but as this case report shows that just doesn’t play out….To me, the most interesting part is if we harbour beliefs based on a particular value in the sim lab – where else does it play out in the care we deliver?!?! These types of discussions could get very interesting – but a whole other rabbit hole that is a mind spiral taking us away from the practicalities of delivering safe sim….sorry for the digression!

    Thanks again for another hot topic!

  • Jennifer Dale-Tam

    Hi Ben,

    This month’s topic, stem and articles have a bit of déjà vous for me. Eighteen months ago I participated in an IP simulation where a colleague of mine was one of the SPs. I have known him for years as we had practiced at the bedside together and have moved into the simulation world in different capacities. During the simulation I “forgot” that he was under the hybrid task trainer and could have easily started an IV on him or done other invasive nursing related tasks. Thank goodness none of this happened, but it did weigh heavily on me after the debrief as I realized how close that could have been. Part of this “forgetting” and buy in, I think in reflection, was due to the realism of the task trainer and the moulage that was used. As the simulation and manikin tech advances with increased physical and conceptual realism (which is fantastic by the way), we as simulation educators must be more vigilant in the safety of our learners but also of the SPs and surrounding environment. Mitigation strategies such as labelling the simulation materials, using pre-sim safety checklist are all great recommendations, but also going back to the basics of a prebrief. Establishing the safe container through orientation to the room and equipment, introducing learner to the SP to make that human connection may help. A challenge does exist with insitu sim, if it’s meant as a surprise, no pre-brief there, or can there be? It comes down to the objectives: is it for learning, test the “system” or both. If for learning, my experience is the pre-brief does not detract from the experience or the learning. To test the system a prebrief may distort the sim, so other strategies like the pre-sim safety checklist or a pre-post supply list where counts are done similar to sponge counts in an OR as suggested by others would be beneficial.
    The sim center and insitu program I work with use many of these strategies already. The support staff of sim techs are well versed in safety. I am lucky in that sense, but that does not negate my responsibility to ensure the safety of all involved pre, peri and post sim.

    Thank you for bringing such an important topic forward.

    • Ben Symon Post author

      Hi Jennifer,
      Thanks for contributing again so quickly on a topic that hit close to home.
      I also have heard of SPs in one service almost being injected with droperidol when a helpful nurse heard the commotion without realising a sim was going on. Thankfully one of the safety mechanisms in place had been to assign a ‘spotter’ to keep the SP safe, and that system worked well with the person interfering quickly and stopping the sim.

      Interestingly at IMSH there were some informal discussions among people I met voicing concern about potential active shooter drills, as accidental involvement of law enforcement could be potentially lethal.

    • Ben Symon Post author

      Hi Eve!
      I agree that the case report is very gripping! And thanks for your compliments on the case study as well :p
      I agree one of the most common misconceptions is the idea of keeping fake medication as somehow safer than using real stuff, and certainly at my hospital there has been significant resistance due to concern about the cost of using real medication.
      I look forward to your future analysis on facilitators beliefs about sim safety!

  • Chris Nickson

    Hi all

    The Wallcur saline case is interesting because it wasn’t introduced into the clinical environment by a simulation team or a sim center. My understanding from the article, is that the clinic bought the fluid thinking that it was sterile saline for clinical use. This is a different problem to the simulation safety issues we generally face, as described by Raemer et al (2018).

    Using real meds/ equipment in situ is better for authenticity and for safety. However, it is not always possible or feasible. An awareness of the safety considerations is vitally important – however, I think we also need to make sure we don’t throw out the simulated baby with the real non-sterile bath water. Some things should be mandatory IMO – cleanup checklists and safety prebriefs, etc. However, I think in situ sims can still be run safely without real meds – e.g. team members drawing up water for injection in the bed space and labelling with simulation only stickers and the discarding post-sim; combined with a pre-brief and post-sim reminder to empty pockets and discard any syringes.

    The case that Raemer et al discuss of simulated “fentanyl” being administered to a paediatric patient is a wider systemic issue than simulation (that doesn’t mean we can’t be leaders here, though). As clinicians we should not be walking around with inappropriately-labelled drugs (simulated or otherwise) in our pockets, full stop!

    Interested, as always, in other perspectives 🙂

    Fantastic discussion stimulus Ben!



    • Ben Symon Post author

      Hi Chris, thanks so much for taking the time to come along this month, it’s always a privilege to have you along.

      I agree that the right checklists and procedures can allow us to safely use fake meds in a real bay, but to be honest, the drugs themselves we use in paeds resus (my only frame :p) are pretty cheap overall, and to me the risk vs benefit of contaminating our resus bay errs on the side of using real drugs.

      Adding onto that, we now have an electronic Pyxis system that requires a thumbprint to remove any drugs from our drug room. This has stopped us using real drugs in our In Situ’s at present, but reading this article has made me motivated to use as much real drug as possible (with exceptions for expensive ones, particularly Prostaglandin for us).

      I think if we are rehearsing our sims, we should be rehearsing how long it takes us to get our resus drugs from the Pyxis unit. Which can be a while!

      • Zachary Buxton

        Interesting to hear PYXIS being a potential barrier. Curious to know if your pyxis won’t allow you to create a temporary “simulation” ID to utilise for drug withdrawals or if it’s a policy/politics issue.

        Also you’re triggering my current fixation on unintentional lessons being taught because of necessary “work-arounds” 😉

    • Ann Mullen

      Your comment about the Wallcur incident is correct. The simulated IV fluid was not introduced into the clinical environment by a simulation employee or program. Yet, as a simulation professional, I am the target customer for such products. Even though I don’t purchase or use the fake IV products, I did feel a sense of responsibility.
      I love your phrase about the sim baby and unsterile bath water!! Simulation offers many patient safety benefits, and we have skills and tools to manage the risk. Some of our standard safety measures translate nicely: sponge and needle counts in the OR are a good example. Counts are mandatory in the OR, and they should be mandatory for in situ drills.

  • Jenny Rudolph

    In 1996 as a first-year doctoral student in organizational behavior, I read an essay that changed the direction of my career. It was Charles Perrow’s analysis of a nuclear power plant near-meltdown. He argued, convincingly to me, that accidents in complex systems were not aberrations but rather, “normal”. He pointed out that when processes that are tightly coupled (think of chemical or physical chain reactions) intersect with complex systems (think: distributed, adaptive, computer networks with multiple interdependencies) none of us should be surprised when small anomalies chain together in unexpected ways to produce catastrophic accidents. As a rock-climber and mom, the idea that electrified me in Perrow’s work was how tiny the seeds of accidents can be: small incidents and errors can align or cascade in unexpected ways into unexpected and unimaginable harm.

    Perrow C. Normal Accidents: Living with High Risk Systems. Princeton, NJ: Princeton University Press, 1999.

    Curiosity about how to understand and prevent such errors turned my work toward healthcare safety and, ultimately, simulation.

    Rudolph JW, Repenning NP. Disaster dynamics: Understanding the role of quantity in organizational collapse. Administrative Science Quarterly. 2002; 47:1-30.

    What is so potent about this month’s topic is that it raises our consciousness:
    Well-intended simulation-based education and quality/safety interventions can undermine the very goals we seek to advance. Like many safety-related industries before us, healthcare simulation faces the challenge of organizing for learning, for safety and avoiding harm.

    I’d like to further the dialogue by focusing on the role of high standards (for safety) and high regard (for well-intended people who may cause harm) by drawing an analogy to research in other high hazard industries. In healthcare simulation safety, as in other settings, it may be tempting to put in rigid controls, institute root cause analysis processes, and create our own version of mortality and morbidity conferences. Those things can be useful, but problematic if not paired with a focus on inquiry and learning.

    In our research on approximately one hundred safety events in the nuclear power and chemical processing industries, my mentor John Carroll
    and I found that the safest organizations balanced high standards for the tight control of safety practices on the one hand, with learning through transparent reporting practices and assuming the best of people on the other. Pairing high standards for safety and high regard for people allowed these organizations to conduct intensely rigorous investigations that examined not only physical processes but people’s mental models and assumptions. In contrast, we found that organizations that used only tight control and punishment of deviations from practice were not able to learn from their mistakes and tended to plateau or even experience deteriorating safety records. Organizations that were “open and nice,“ but failed to hold themselves to high standards were also not able to build good safety records.

    Carroll JS, Rudolph JW, Hatakenaka S. Learning from experience in high-hazard industries. Research in Organizational Behavior. 2002; 24:87-137.
    Carroll, JS, Rudolph JW. Design of high reliability organizations in health care. Quality and safety in Health Care. 2006: 15 Suppl 1: i4-9.

    As we turn the safety lens on our own simulation in healthcare practices, it seems like a challenging (dare I say confronting?) opportunity to “walk our talk.” We suddenly have to apply all the skills and techniques we have asked our participants to develop, on ourselves. Yikes!

    • Ben Symon Post author

      Thanks Jenny for your eloquent response and taste test of your experience in the nuclear and health care industry. I really appreciated in your response that while you highlighted the Amy Edmondson style ‘Organising to learn’ style model of accountability, that you also highlighted that ‘Open and Nice’ isn’t enough on it’s own.

      I worry sometimes that the pendulum in some institutions swings too far away from Punishment to Cuddley without some level of accountability in between.

      • Ann Mullen

        Jenny’s comment about high standards for safety and high regard for well-intended people who may cause harm rings true for me.
        I have heard many stories of simulation mishaps, and often think “that could have happened in my program” or “yes, I had a similar incident!”
        Typically, the incidents do not result in an injury and are not reported, so we can’t learn from them.
        I am closely following this JC and looking forward to more discussion!

      • Farrukh

        I just finished Teaming by Amy Edmondson, feel that I have to read it a second time to really digest some of its content. Jenny’s comment on balancing high standards with high regard very much resonated with me, and also fit well with the Teaming book. High reliability organizations are complicated and need to meld quality improvement with psychological safety and transparency. When doing in-situ, or even when running simulation in the lab, when orienting my participants I acknowledge the labels we use and reinforce the importance of leaving all equipment at the lab to avoid bringing it accidentally to the hospital. I’ve always focused on the first aspect, the high standards, but not often the high regard.

        I bring up the basic assumption in my pre-briefs, but now I am reflecting on if I discuss this with my team regularly also. Am I creating the same psychologically safe environment that I am teaching? I hope I am. High standards are simpler, it is a written policy that can be disseminated, which is why they are so frequently put together and emailed. I need some personal reflection after this and see if I walk the talk, and if I can do this consistently.

  • Sonia Twigg

    In hospitals we manage safety hazards every day. Surely simulation is simply subject to the same rules, standards, and quality monitoring as any other hazard?

    Which got me wondering exactly what safety standards hospitals are obliged to adhere to? Obviously there are standards for storage, prescription of and checking of drugs and fluids, and there is a requirement for M&M, and root cause analysis of major incidents with subsequent registering of the risks and management plans. Any others?

    This is of course a tragic but unusual mistake – that cannot occur again now that the FDA has removed the non-sterile fake fluid. I think a more common concern is the danger that that sim equipment/fluids/drugs could get mixed up with the real thing.

    Perhaps it’s best if in-situ simulations use real fluids/ medications/equipment?

    But sims done in separate, non-clinical areas have less risk of inadvertent mix up and this risk might be safely managed by checking equipment/ fluids/ “drugs” before and after the sim.

    As simulation becomes common, the pattern of hazards will become more obvious – and the solutions worked out, described and incorporated into hospital culture.

    PS. What a thrilling story! I can totally see how this could happen in real life! Do you think a pre-sim safety brief could have avoided this outcome? 🤔

    • Ann Mullen

      I agree that we should employ our usual safety standard in sim situations. I think that we need an extra level of caution for simulation because we are asking people to look at fake things and act as though they are real. The line between real and fake is quite blurry.
      There is no one right answer to the real vs fake medication question. It is a risk-benefit calculation that is unique to each setting.

      To clarify, the FDA has not removed the fake unsterile fluid; it is still sold by several vendors. They did issue an order for warning labels. Unfortunately, labeling is a weak safety measure, and there is no standard labeling requirement. The Foundation for Healthcare Simulation Safety has produced a standard label and logo :
      We were quite pleased to see that Wallcur has adopted this label for all their products, but this is only one small part of a safety strategy.

  • Melissa Cirino

    Hello All,

    I am a new simulation specialist starting only 7 months ago. I have really enjoyed following this conversation as I had not thought much about the different safety issues based on the sim environment.

    Working in a sim center I feel the chances of sim meds reaching real patients are reduced. Our participants are given a prebrief about not hurting the actors. As an actor in our scenarios I appreciate the prebrief and know it works because I have had participants check in to make sure I would not be hurt if they proceeded.

    Looking forward to seeing more posts on this topic.

    • Ben Symon Post author

      Hi Melissa,
      Thanks so much for joining us for the first time! It’s great to have you along!
      I agree the risk in a dedicated sim center is low, although I also note in some of Ann’s links above that there are some surprising events still reported.
      Great to hear a good prebrief is helping you in your centre.

    • Janine Kane

      Hi, I work in Nursing ed SIM too and have had near misses which I thought would never happen in such a tight controlled area😬 we wouldn’t disclose too much about the scenario, e.g. giving s/c injection. Did the pre brief, talked about sires etc but stated we would give in abdomen, gave half the students a pt scenario, appropriate clothes, fake abdomens props etc. then bought students into the 4 bed ward one by one so they would be well supervised etc. except on this particular day as I and my student approached the pt, did 6 rights etc, the door opened and another staff member popped their head in to ask if they could borrow something. I heard a screech from behind me and my student had decided she would inject the pt in the arm and not the belly! No idea why as we had talked about position etc. stopped the student in time but now make sure everyone knows it’s belly only by getting them to practice in front of each on a fake abdomen . 😂

  • Shannon McNamara

    Ben reached out for “Safety II input,” and I immediately wondered, what on earth would that look like? Reading through the comments here, I appreciate the thoughts folks have shared on the articles & situations. I’ve shared many a nervous thought about how our simulations may be introducing risk into the clinical environment and how we can do our very best to mitigate that risk and add quality and safety to our work through simulation. Watching people practice doing crics on live patients makes me feel ill thinking of a slipped scalpel (despite all the neck protectors) and we are careful to clean up our in situ cases to prevent situations like those discussed.

    So what does Safety II look like here? What does it mean to study the every day work of simulation safety, not just the critical events? What does it look like to value the wisdom of the front line experts? What does it look like to value excellence and expertise, to standardize where possible, but also to create room for the necessary adaptivity that a complex system requires? *pondering face*

    I often consider the psychological safety we create in simulation. We’ve talked a lot here about the physical safe container here, and the sentinel events that came out of a very unsafe container. I wonder how our everyday simulation culture is doing with our psychological safe container as well? What’s our every day practice? What do the front line experts think? How are our learners doing? Is the scene safe for learning & growth, or are there hidden hazards there, too?

    As this is a case about murder (thank you Ben), I think this leads us well to the ongoing discussion about death in simulation and the safe container. My colleagues and I talked about this recently in a separate journal club with separate articles about the “debate” about the death of the simulated patient, the culture of blame in medicine, and second victim syndrome & secondary traumatic stress. In my experience, those are all inextricably linked – a learner makes an error in sim, the simulated patient dies, they are now the “simulated second victim,” and depending on the debrief, they may be blamed for that patient’s death. The debate about how the manikin should die (or not) calls for more empirical evidence. Calhoun AW, Gaba DM. Live or Let Die. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2017;12(5):279-281. doi:10.1097/sih.0000000000000256.

    I argue that we need more context for why it matters and to define what “empirical evidence” we need – not just what we can measure, but what meaningful measures look like. Measuring learner anxiety after a sim is not necessarily a meaningful outcome. We need more qualitative literature on learners experiences of death in simulation to better understand the impact these learning experiences have.

    As we move towards a Just Culture in medicine that seeks to move towards blame-free reporting, we are trying to recognize ‘human error’ as inevitable in a complex system and using human factors to create harm-mitigation systems to keep our patients safe. Shame and blame have no place here. But have we eradicated those traits from our culture of simulation debriefing? Is there a latent hazard in our everyday practice?

    Though many simulation facilitators value those ethics, how are actual simulations around the world running? Simulation technology doesn’t have any inherent values. Once someone buys a manikin, they can run their sim sessions however they want. What is the actual culture of simulation that learners experience around the world?

    As we do more clinical debriefings, perhaps even next to a patient that just expired, and ask, “How can we do better next time?” Are we doing the right thing? Is that helping our colleagues, or is that exacerbating the secondary traumatic stress of watching someone die at work?

    As we struggle with the crisis of physician suicide, where we know that 10% of medical students experience suicidal ideation during medical school and the point prevalence of PTSD in Emergency physicians is 15% at any given time, are we simulationists creating a safe container where all can grow? Or are we doing more harm than good?

    I don’t know. But I think these are questions that we must take just as seriously as those about a stray syringe.

    • Ann Mullen

      What an elegant piece of writing. No surprise; I am a big fan of Dr McNamara’s.

      I agree that simulation safety is not limited to physical safety, and the danger of psychological harm can be underestimated. When we run a simulation case, even the most basic emergency could trigger a clinician to re-live a painful experience. When clinicians are involved in a difficult case the memory is indelible. A simulation of a similar event can be traumatic, and I worry that we may be opening an old wound. Clinicians have learned to put aside their emotions in order to function at work; what happens when they leave the simulation at the end of the day?

      I believe that part of the answer is to be aware of the risks and to talk with our sim colleagues about this topic. I started mentioning in my pre-brief that simulation can remind us of past experiences, give permission to “time out”, ask participants to let us know if they need help. We also display our employee assistance program brochure and cards in the center.

      I used to think that our weekly medical student simulations were relatively easy; the students often told us that they loved them and that they learned so much. I think that I started to take the safe container for granted. Then I had an interaction that was an eye-opener for me. After one of our routine cases, and an uneventful and “usual” debrief facilitated by a skilled and supportive chief resident, I ran into one of the students later that day. He said “Can I ask you a question? Are we the worst students you have ever seen?” I was shocked and saddened that he felt that way and that we had been oblivious to his negative view of himself. We had a good chat, and I think that I was able to receive some of his distress. It reminded me of how vulnerable our learners are and that we must be vigilant about the safe container.

      • Shannon McNamara

        Ann – thank you for sharing your thoughts and for your kind words! I have often become too comfortable with assuming the safe container is there and forgotten to reinforce it. Fundamental!

        After writing here, I stumbled upon a teacher writing about her experience on Twitter with emergency preparedness live-shooter trainings in a school setting that really exemplifies the concerns I wrote about. She was really troubled by her experience, as there was little attention paid to establishing a safe container or psychological safety. Many other teachers wrote in with similar concerns. It seems that very little attention is paid to psychological safety in many of these trainings, and that many operate under the assumption that fear is productive for learning. It’s very concerning.

        When I push myself to go back to the basic assumption here – which I admit is a big struggle for me, especially when there are significant financial conflicts of interest for those doing for profit trainings – I wonder if those leading these trainings just don’t know any better. I imagine those in law enforcement were trained with live fire training operating on more of a simulation stress inoculation model and are likely repeating that model here. I am very concerned that people are leading in situ simulation trainings in schools without clearly following best practices like establishing psychological safety. I wonder what the healthcare simulation world could offer the emergency preparedness world in helping create more learner centered and less traumatic trainings.

        I also wonder what the point of trainings like this are. I can’t imagine that an active shooter situation will ever go well. Perhaps more of a systems approach focusing on designing an environment where it is easy to do the “right thing” and then practicing basic behavioral objectives without creating a high fidelity active shooter scenario that traumatizes everyone would be more productive. As someone mentioned: “we don’t set fires at fire drills.”

        The basic guidelines of sim – creating clear learning objectives, doing a good prebrief, matching fidelity to objectives, clearly defining training/behavioral vs. systems goals – would be very helpful in these situations. Based on the learner reports, it appears that many of these trainings are doing much more harm than good.

        • Ben Symon Post author

          Hi Shannon, thanks so much for all of your thoughts and comments. I’ve enjoyed watching the conversation play out on twitter. I feel a little unqualified to speak on some of these matters, particularly active shooter drills, due to the scarcity of these events in Australian culture. Thanks so much for providing a gateway towards reflection on these issues!

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