IMSH 2020

IMSH 2020 was a big success!

This was our first time hosting a booth at the International Meeting for Simulation in Healthcare. We had a steady stream of visitors to our booth; many of them were already using our safety labels. Others were using their own labels, and we discussed the advantage of a standardized label for easy recognition.

Although labels are the most visible aspect of our work, it is equally important to think about other aspects of simulation safety.  We had lots of conversations about possible risks. Ideally, simulation planning should include assessment of risks and mitigation strategies.

We presented a workshop:  First Do No Harm: Strategies to Prevent Simulation Accidents. After an introduction to the simulation safety concepts, workshop participants shared their examples of simulation mishaps and mitigation strategies.

Some examples:

  • Inadvertent activation of personnel/ resources: There were several examples of Code/Rapid Response Teams being summoned in error. These “false alarms” are a recurring problem, and they can disrupt clinical care. We have heard stories of blood transfusions ordered,  ECMO team and pediatric transport team being summoned to a simulation.
  • Keeping mannikins clean is challenging, and one team noted signs of mold growth despite usual cleaning procedures.  Cultures were sent to the lab, and they were dismayed to learn that the results were positive for Pseudomonas.  This is especially worrisome if mannikins are brought into patient care areas, which could be very risky for immunocompromised patients.
  • Despite instructions to the contrary, people give mouth to mouth ventilations to the mannikin.
  • Risks to standardized patients (SP) were described.  Allergic reaction to moulage have happened. Sometimes clinicians forget that the SP is not a real patient, and get “carried away” e.g. attempt IV or other invasive procedures.
  • Problems with medications are quite common.  Well-meaning donations of expired drugs can be a logistical challenge.  One program discovered narcotics in a storage closet, which had to be reported to authorities and required extensive follow up.
  • Expired supplies or procedure kits are saved for training purposes. Often these items are not quarantined or labeled, and could end up in patient care area.
  • Decommissioned equipment is sometimes used during simulations. These may not be up to current code, and can present risk of fire or shock.

Risk Reduction Strategies

Some programs install mechanical lift (Hoyer lift or other brand) for moving heavy mannikins.  This is also used for staff training.

Safety culture : encourage everyone to be empowered to speak up if they see any dangers and “stop the line”

Report accidents and near misses via incident reporting system.

Safety officer / safety observer. This person is assigned to watch for any unsafe conditions, and intervene. This is especially important during multi-patient simulations.


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