By David M. Gaba, MD, Staff Anesthesiologist and Founder & Co-Director, Patient Simulation Center at VA Palo Alto Health Care System; and Associate Dean for Immersive & Simulation-based Learning and Professor of Anesthesiology, Perioperative & Pain Medicine, Stanford School of Medicine
I’m honored to be the 2020 recipient of the John M. Eisenberg Patient Safety and Quality Award for Individual Achievement. The award in part recognizes my work in simulation, especially high-fidelity mannequin-based single and multiple participant scenarios, as a means to study and improve patient safety.
Simulation has become fairly common for early learners in health care professions, as well as for graduate medical education (interns, residents and fellows). What many may not realize is that there are a host of other uses of the many different modalities of simulation beyond straightforward training.
First, consider that simulation is a technique, not a technology. All the various forms of simulation – non-technological and technological – are all parts of a single spectrum. Experts in health care simulation choose the modality that will best serve the purposes such as:
- ·verbal simulation of a situation
- medical history and physical examination of a standardized patient actor
- part-task procedural training
- mannequin-based recreations of complex clinical situations.
In each, clinicians and actors play roles to allow simulation participants to experience the challenges of real patient care.
Uses Outside of Teaching
Having said that, there are several ways simulation can be used to address patient safety issues other than for education and training.
- In situ simulation for systems probing: Many training simulations take place in a dedicated simulation center – an educational facility where teaching and learning is the primary goal. But simulations also take place either in a real patient room or other clinical setting such as the emergency department or operating room (in situ); or, when clinical space is scarce, perhaps peri situ, very close the actual point of care (such as in the unit’s conference room or hallway).
Sometimes in situ or peri situ simulations are scheduled teaching exercises, but even more powerfully they can be unscheduled events meant to probe how the clinical system actually works when faced with challenging circumstances. Educational simulations are primarily aimed at learning, whereas systems probing simulation has a primary goal of determining what worked well and what did not in the clinical workplace, with learning as a useful byproduct. Information learned from systems probing simulations can then be used to develop systems fixes – a much more powerful approach to quality improvement than training large groups of personnel to do something differently.
- Designing, planning and rehearsing for new programs or facilities: Simulations using different modalities have been highly beneficial in preparing for and evaluating the need for change, but they are still unfamiliar to many clinicians, administrators, architects and engineers. This has been especially useful for clinical activities of high complexity, high-intrinsic hazard, and complex patient care technology. Since simulation is often easier than undergoing unnecessary construction or dealing with an adverse event, the up-front investment can, over the long term, pay for itself via fewer problems, faster project completion and lower patient safety risk.
- Formative (or even summative) assessment of clinicians: Simulation offers a unique window on clinical work that is complementary to more traditional windows, allowing triangulation across them. Traditionally, one might review case logs or reports of prior challenging cases. Retrospective reports are often limited and outcome-biased.
Similarly, clinicians can observe one another doing clinical work. This is prospective, but much clinical work is routine and highly challenging situations don’t arise too frequently. Simulation is prospective and can be designed for desired complexity; the downside is there is not a real patient.
- Supporting root-cause analysis and/or medicolegal defense: The analysis of some adverse events can be aided by simulation in a legal setting. In some cases, simulation can be used to evaluate the physics, chemistry, mathematics and physical environment surrounding an event. More commonly, cases revolve around a clinician’s decisions and actions. While simulation cannot currently fully replicate a patient’s physiology, it may be useful to understand what an expert might do and what pitfalls are common. Using simulation to educate juries about the normal work processes used by the average clinician in a relevant, routine case may be useful since judges and juries likely have modest knowledge of normal practices in different clinical settings.
These are only a few aspects of simulation that have proven useful in addressing important issues in patient safety. In addition to continually making advances in the technologies that support simulation efforts, clinicians are limited only by their imaginations. Hence, to borrow a phrase from Theodore Roosevelt, when it comes to simulation, and in fact to all work on improving quality and safety for all patients everywhere, I encourage everyone think creatively to “dare mighty things.”
David M. Gaba, MD, is Staff Anesthesiologist and Founder & Co-Director, Patient Simulation Center at VA Palo Alto Health Care System; and Associate Dean for Immersive & Simulation-based Learning and Professor of Anesthesiology, Perioperative & Pain Medicine, Stanford School of Medicine. Dr. Gaba was recently awarded a 2020 John M. Eisenberg Patient Safety and Quality Award for Individual Achievement for his lifetime body of work in simulation, crew resource management and cognitive aids. To learn more about Dr. Gaba’s impactful career, please visit the Eisenberg Award webpage.