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