Using in-situ clinical simulation to identify system errors within complex healthcare organisations

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Simulation has been used for many years as a means of showing the eventual real effects of alternative conditions or actions and can be used when the real system cannot be engaged either because it may not be available or it may be dangerous or unacceptable to do so.

In the complex systems within healthcare, the increasing use of clinical simulation provides a safe environment where participants can learn from their errors without causing harm, thus reducing risk and improving patient safety. Simulation is seen as an innovative means of bridging the gap between practicing on models and treating real patients and is gaining a central role in medical education. Hi-fidelity simulation has been developing over relatively recent times and its strength is widely recognised as a method of enhancing educational messages and examining clinical elements alongside human factors and ergonomics, thus reducing risk.


A more recent enhancement is the development of in-situ simulation which takes simulation into the clinical area as opposed to a simulation centre. Facilitating realistic in-situ simulation requires considerable expertise, equipment and full support from senior clinicians as well as engagement from local staff. A key element in the delivery of this type of training is to ensure that participants understand that this is not any form of test; rather that it is an invaluable learning opportunity.
In-situ simulation has the ability to examine expertise by capturing performance when and where it occurs routinely. Also, importantly, it can be used to identify system errors which would potentially otherwise remain undetected if the same simulation occurred in a purpose built educational environment.
In-situ simulation in the Royal Derby Hospital is undertaken in the following clinical areas.

• Emergency Department
• Intensive Care Unit
• Renal Unit
• Renal Ward
• Theatres
• Theatre Recovery
• Obstetrics
• Children’s Emergency Department
• Paediatric Wards


By using in-situ simulations of appropriate clinical scenarios the following issues and system errors are just some examples of those which have been identified.

• Theatres – drugs urgently required were kept in a locked cupboard in a separate theatre block several minutes away
• Emergency Department – equipment issues were highlighted in 3 separate simulations, one of which was that the Resuscitaire (for resuscitation of neonates) in ED was a different make/model to those used in Obstetrics, therefore the midwife was unfamiliar with its use
• Obstetrics – in-situ simulation highlighted that essential drugs had not been re-stocked following a real patient event earlier in the day
• Paediatric Ward – the location of essential equipment had been changed in order to improve the system however not all staff groups were aware of the change


In conclusion, there are several underpinning educational theories, models and frameworks supporting clinical simulation as an effective method of teaching and learning, coupled with its ability to integrate technical skills with human factors and ergonomics. The increased use of in-situ simulation is now providing evidence of system errors occurring within complex multi-faceted healthcare systems which could otherwise go unnoticed, enabling alterations and improvements to reduce risk and enhance patient care.

Date & time

7-8 June 2016

NCTL Learning and Conference Centre, Nottingham

What is a Complex System?

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