Simulation Safety Policies: Where to Begin?

We were thrilled to read the recently published work by Dr. Victoria Brazil, emergency physician and medical educator, based on the Gold Coast, Australia. As the medical director of the Gold Coast Simulation Service, she leads in situ simulation programs in a wide range of settings. Dr Brazil, Clare Scott, Jack, Matulich, and Brenton Shanahan developed a simulation safety policy and published a comprehensive and practical guide to help others to do the same.

The article, Developing a simulation safety policy for translational simulation programs in healthcare, was published in Advances in Simulation in January 2022. The authors shared their process for developing a policy as well as the challenges in translating policy statements into practical application.

Advances in Simulation is an open access journal; there are no barriers to accessing this treasure trove of  information. We share some highlights from the paper and encourage you to take advantage of this valuable resource. 

The authors identify important steps in the policy development process:

  1. Form a steering group for development and implementation of the simulation safety policy and identify relevant stakeholders required for advice and approval.
  2. Identify existing safety procedures for the health service/ educational institution that are relevant for the simulation program.
  3. Incorporate simulation safety practices required in SSH accreditation processes and Raemer’s ‘Ten commandments’ 
  4. Consider the nature and extent of predicted safety risks, based on reports in the literature and local experience—adverse events and near misses.
  5. Prioritize medication safety and liaise with health service pharmacy representatives.
  6. Effectively communicate the existence of the simulation safety policy, and the need for staff involved in simulation delivery to comply with it.
  7. Enable simulation faculty to conduct safe simulation sessions that are compliant with the policy, including structured briefings, cognitive aids and environmental cues.
  8. Develop a reporting process for simulation related adverse events or near misses, preferably integrated within the health service clinical adverse event reporting framework.

They also share practical tools for implementation, with excellent graphics and photos. These tools are directly connected to # 7 above. It is not sufficient to have policies; simulation professionals need structured templates, signage, labels and cognitive aides to carry out the policies.


  • Cognitive aid for simulation delivery teams conducting translational simulation activities
  • Signage and staff uniforms to identify the simulation delivery team. 
  • Simulation safety officer is designated for each in situ simulation
  • Safety briefing incorporated into the overall simulation delivery team briefing and again during participant introductions and pre-briefing. 
  • Integrate simulation safety procedures into faculty development programs.

Safety checklists are an important tool for all simulation planning, and especially vital for in situ simulation.  The Foundation for Healthcare Simulation Safety has additional examples on the website.  We encourage you to use these to guide your team to develop your own checklist and customize it to meet the needs of your organization. 

It is important to inform everyone in attendance about the simulation activity.  Clear signage can be one part of this messaging. This can reduce the chance of causing distress and confusion for visitors or other staff who are not involved in the simulation.

The simulation safety officer has an important role. That person leads the work of  maintaining situational awareness, alerts the team to any safety concerns, and is empowered to halt the simulation. However, it is important that simulation teams and learners are included in this effort, so we strongly support the practice of including safety briefings in the sim team briefing and in the course pre-briefing. 

 It is important to inform everyone in attendance about the simulation activity.  Clear signage can be one part of this messaging. This can reduce the chance of causing distress and confusion for visitors or other staff who are not involved in the simulation. 

Simulation is a complex activity, taking place within a complex healthcare system and we should expect the unexpected. We are grateful to the Gold Coast Simulation team for doing this work and for writing this useful guide. 

Infection Safety: In-Person Simulation Activities

Many simulation programs closed or limited their in-person simulation activities as the global Covid-19 pandemic began to spread throughout the world.  During this time, many simulationists provided invaluable service to their institutions via on-line, individual, advisory or other modalities.  In many places, in-person simulation activities are beginning to reopen, and the simulation community is developing and implementing safety plans to limit or prevent the spread of infection in their programs.  As simulation activities vary by locale, participant groups, institution type, location of activities, supplies and equipment it would be difficult for any one set of guidelines or protocols to satisfy every need.

The concepts of confidentiality contracts and fiction contracts are familiar to simulationists; we propose adding a safety contract. The educator or institution provides explicit information about what they are doing to maintain safety, and what is required of those who participate. The safety contract can be communicated via pre-course announcements, email or website postings, and reinforced at the start of the activity.

Here we attempt to present a framework for thinking about infection safety, especially with respect to the SARS-COV-2 virus, in the coming days. We have borrowed, in part, some of these ideas from an interview of Asaf Bitton, MD at Ariadne Labs and an article by Atul Gawande, also of Ariadne Labs at the Harvard School of Public Health in Boston.  Both articles were published in the New Yorker Magazine: Bitton and Gawande, respectively.

This framework is based on five elements each starting with the letter D :  Demographic, Density, Duration, Distance, and Disinfection.


One critical step in developing an infection safety strategy is to consider the characteristics of the participants and staff.   There may be people with vulnerabilities; how can you maintain safety while respecting their privacy? Are the people in this group living and working in a “hot spot” for covid-19?  How will you respond to an increase in community infection rate?  What factors will you consider when deciding whether to cancel or modify your program? How do you reliably and consistently check those thresholds and actualize a change in your program?   Are there factors such as sick leave policies or program deadlines that would inhibit staff and participants from staying home when they are not well? Are the participants working in places where they are at particular risk?  Which health screening method will you use and how will you respond to a positive screen? Are you checking temperature?Can you align your program with existing resources such as occupational health or student health services?

Density: Greater numbers of people involved in a simulation activity can create greater risk. Are there ways to minimize the density of people?  Will staggering the participants into smaller groups be helpful?  Can the physical space elements such as seats, tables, screens, stations be adapted to reduce density?

Duration:  The duration of exposure to potential sources of infection seems to be a critical variable in the risk equation.  Can you minimize the time that participants are in close contact?  Can some parts of the simulation be done remotely without losing effectiveness?

Distance:  Though six feet or two meters is the “social distance” standard, the actual transmission distance for SARS-COV-2 infections is situation dependent.  People speaking loudly or shouting is greatly different than people speaking softly through masks.  Can maximal distances between people be achieved and maintained for most of the simulation activity?  Are there particular parts of the event that naturally will decrease the safe distancing that could be mitigated by changes in layout, supplies, barriers, or other means?   Consider how to manage food and drink.  Since masks would be removed, do you prohibit consumption of coffee/ snacks when groups are gathered for briefing and debriefing?

Disinfection:  The current public health guidance suggests there are two major routes of transmission, respiratory droplets and fomite transmission (touching a contaminated surface and then moving that contamination to the mouth, nose, or eyes).  Masks reduce the risk of respiratory transmission and much has been written about the relative effectiveness of different kinds of mask technology.  What kinds of masks will people use for the simulation activity?  Will they be provided?  Many areas are experiencing shortages of masks and it is important to choose the right device to protect participants while assuring adequate supplies are available for clinical use.   How will wearing them be encouraged and enforced?  Fomite transmission, while thought to be less likely than respiratory droplet transmission, is best limited by hand hygiene, appropriate use of gloves, and cleaning common surfaces.  What disinfection measures are in place that are reliable and consistent in your simulation activity?  Is there handwashing readily available?  Is hand sanitizer available when hand washing is unavailable or impractical?  Are gloves available and is there guidance on when they are required or recommended?  By what mechanism, soap and water, chemical (hypochlorite, alcohol, peroxide, etc.), radiation (ultraviolet), temperature (sterilization) will each surface and simulation accoutrement be cleaned and how often?


The challenge of providing care in this pandemic have only amplified the existing opportunities for simulation to improve our work.  The importance of overcoming new barriers to delivering training are especially profound now where both the benefit and the risk are increased.  We hope to have provided useful prompts for help simulationists plan a new and safe model of training.



Simulation Supplies in a Pandemic

Simulation professionals are providing valuable services during the COVID 19 pandemic, including PPE training, team practice, and systems testing.  Simulation programs have quickly responded to the need to provide virtual clinical experiences for students who are not allowed to work in the clinical environments. These strategies and tools have been generously shared online so that all can benefit, and to avoid duplication of effort. 

In response to supply shortages, simulation programs have supported clinicians with donated PPE and other equipment. Many programs have canceled center-based classes, and are transitioning to online or in situ education.  We recently heard from a colleague who recognized a possible safety threat related to this situation. It is very helpful to share unneeded supplies with clinical units, however this may lead to unintended consequences.  

Becky Damazo, Rural SimCenter Director and Professor of Nursing at California State University, was concerned that people may look for supplies in the simulation center. The center was closed, and there would be no staff available to monitor the supplies. Well-meaning people may not be aware which items are appropriate for clinical use.  Matt Ross, simulation technician, offered a creative solution: he applied the Not for Human Use labels across the doors to the simulation supply cabinets. This provides a warning to those who may be “shopping” for supplies, and acts as a seal to discourage people from opening the cabinet or closet. It was also an alert that supplies may have been taken and allowed for inventory tracking.image0

Thanks Becky and Matt for sharing this helpful suggestion!

We recommend that simulation programs:

  1. Use a meticulous process to ensure that any item given to clinicians is safe for patient use, unopened, not expired etc. 
  2. Institute measures to control access to simulation supplies to avoid inappropriate use. 

Please share your experience with us!

Contact us through the website or on Twitter @tokeepsimsafe


COVID-19 and Simulation Safety

It seems like every hour provides new challenges in responding to the global pandemic of COVID-19.  Healthcare educators, including those practicing various forms of simulation, are being confronted with difficult decisions about their work.  Should we continue training? Should we close down our operations? What about converting to on-line simulations? Is using PPE for training wasteful?  What is our role?

FHSS’s position is that each situation needs to be carefully assessed according to a thoughtful risk / benefit analysis.  If the benefit truly outweighs the risk, then what risk mitigation strategies can be applied to improve safety?  

We believe in the guiding principle of: first, do no harm.  Does the educational or operational benefit of the simulation activity outweigh the risk to personal health or public safety?  In most cases, education and training unrelated to the pandemic response would fail this test.   If the participants in simulation are students, it seems very unlikely that physical presence simulation can be justified during a pandemic.  If the participants are hospital workers, it is important to consider that this population is at especially high risk for infection and carriage of the virus.  Also, the loss of a healthcare worker to the illness is devastating to the battle against the pandemic. This weighs heavily on the risk side of the equation.

In considering the benefits,  alternatives such as live stream video, teleconferencing, tabletop exercises, or other creative forms of practice should be contemplated first.  Only if these methods are insufficient should physical presence simulation be assented to. 

If an educational program is deemed highly beneficial and the physical presence of learners or of educators and educational staff is deemed worth the risk, a number of mitigation questions should arise.  Can the exercise be conducted with strict infection controls in place?  Can physical distance be maintained for participants and educators?   If the simulation requires people to work closely together, can infection control practices be maintained throughout?  Is there a way to minimize the drain on resources so that it does not impact the patient care operations?  

We were heartened to see safety focused questions raised on social media. For example, a twitter poll by Victoria Brazil asked simulationists to weigh in on the use of real vs. simulated PPE, sparking conversations about the balance between using limited PPE resources with need for practice.  The topic was discussed on Simulcast:  (Episode 97 COVID 19  Sim).  Several Twitter posts described scaling back use of PPE or using creative mock PPE. Others used full PPE and shared lessons learned to guide others’ efforts. Either way, we were pleased to see the thoughtful decisions being made and discussed openly. 

Finally, there are inherent biases present in making these kinds of decisions.  Simulation educators are dedicated healthcare workers and are committed to actively helping.  Healthcare workers pride themselves as willing to take risks in the care of others. Their colleagues on the front lines are truly battling this risk and, in some cases, losing that fight.  It is natural to want to stand beside those heroes. There is the desire to feel relevant, be a contributor, and be appreciated by an organization and colleagues. Simulation education does not exist in a vacuum – it exists to serve the interests of patients and colleagues. Consequently, decisions about training mustn’t be made in a vacuum and should actively engage independent individuals and experts, especially those we hope to support.

We would love to hear your thoughts. 


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.


A Somber Anniversary

Five years have passed since we first heard this shocking news:

Adverse Events Associated with Administration of Simulation Intravenous Fluids to Patients

On December 23, 2014, the New York State Department of Health (NYSDOH) was notified of adverse health events in two patients who had been inadvertently administered nonsterile, simulation 0.9% sodium chloride intravenous (IV) fluids at an urgent care facility. ….

Source: Notes from the Field

This event was shocking and distressing. The thought that simulation could inadvertently cause harm to patients goes against our core values! Simulation educators provide a vital service to make healthcare safer, not to cause harm.

This incident was the catalyst for the formation of the Foundation for Healthcare Simulation Safety, and the 5 year mark seems like an appropriate time to think about the state of healthcare simulation safety, what has been accomplished, and plans for the future.

2019 in Review:

6000 Website visits from 66 Countries

71 Label orders fulfilled

441 Label templates downloaded from website

Spanish and Portuguese translations of the editorial: Simulation Safety First; An Imperative

Plans for 2020

IMSH workshop :  First Do No Harm: Strategies to Prevent Simulation Accidents. This is the 4th time we have presented this workshop; each time we hear more examples of simulation mishaps and mitigation strategies.

IMSH Booth This is our first time hosting a booth at the International Meeting for Simulation in Healthcare.  




2019 Year in Review

Over the last few years, the message of simulation safety has gained strength.  Thanks to all of our friends and colleagues for doing your part to keep sim safe!

6000 Website visits from 66 Countries

71 Label orders fulfilled

441 Label templates downloaded from website

Spanish and Portuguese translations of the editorial: Simulation Safety First; An Imperative

Simulation Safety was a featured topic on Simulcast Journal Club.  The online journal club discussed the Practically Saline article; a wide-ranging discussion followed.

Dr. Catherine Morse invited Ann Mullen to contribute a section on simulation safety to the article: The Changing Landscape of Simulation-Based Education, published in August 2019 in the American Journal of Nursing.

Plans for 2020

IMSH workshop:  First Do No Harm: Strategies to Prevent Simulation Accidents. This is the 4th time we have presented this workshop; each time we hear more examples of simulation mishaps and mitigation strategies.

IMSH Booth This is our first time hosting a booth at the International Meeting for Simulation in Healthcare.  We hope to see you in San Diego! 


Simulation Safety at UAB

Our colleagues at the University of Alabama have embraced simulation safety!  During a recent visit to the Office of Interprofessional Simulation for Innovative Clinical Practice (OIPS), several examples of simulation safety practices were evident.

Medication Labels

The fake medications are clearly labeled. More importantly, the task of labeling is assigned to a specific person, who checks regularly to ensure that any new items are labeled “Not for Human Use, Education Only”

Policy for Actual Emergency

The center has a policy for managing real emergencies, which is clearly posted throughout the center. The simulation center looks like an authentic clinical environment, and if a learner or staff were to become ill or injured, there could be confusion or delay.  Clear instructions are posted with emergency phone numbers to summon help for real events.

In Situ Simulation 

In situ simulations are conducted regularly by the OIPS team. These drills are conducted to test the hospital system and to identify strengths, weaknesses, opportunities, and threats in clinical systems, the environment, or among teams.

The OIPS team presented a workshop on in situ simulation at the International Meeting on Simulation in Healthcare (IMSH) in January 2019.  The panel provided a comprehensive guide for implementing an in situ simulation program. April Belle, MSN, RN, Director of In Situ Simulations, provided many specific recommendations for reducing the risk to patients and staff during these drills.

The OIPS website section on in situ simulation features a photo of the team transporting a mannikin to a drill. The IV bag is clearly labeled with a FHSS safety label.  Many thanks to the team for their commitment to simulation safety!

Simulation Safety First: Portuguese Translation

We are happy to share another translation!

The simulation safety editorial is now available in Portuguese, thanks to the work of our colleagues from Brazil: Dr. Henrique Pierotti Arantes  and  Carolina Alexio.  Dr. Arantes is the coordinator of the IMEPAC Araguari – MG Medical Course in Araguari, Brazil.  More information about the IMEPAC Simulation Center can be found here.

Thank you Henrique for your time and talent!

The translated version is here: Juramento

Simulation Safety First: Spanish Translation

The  message of simulation safety is spreading to our Spanish-speaking colleagues!

We are so grateful to Priscilla Carmiol-Rodríguez for translating our editorial to Spanish. Priscilla teaches at at the University of Costa Rica’s Healthcare Simulation Center, and  has worked in healthcare simulation for over 7 years. The Simulation Center is located at the Nursing School, and is an SSH accredited center.

Our colleagues generously agreed to review the translation, and provided valuable feedback. Demian Szyld, MD is the Senior Director of the Institute for Medical Simulation at the Center for Medical Simulation in Boston.  José Mª Maestre, MD is the Director of Educational Innovation at Virtual Hospital Valdecilla in Santander Spain, and is on the faculty of  Institute for Medical Simulation, Center for Medical Simulation in Boston.

We thank Pricilla, Demian and José for your time and talent!

The translated version is here: Seguridad Primero