Published Reports

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Simulated IV fluid administration led to serious complications

This case report describes one example of  inadvertent use of simulated IV fluid.

In New York and other US locations, simulated IV fluid was mistakenly ordered and administered to patients. The commercially prepared simulated IV solution is an unsterile fluid, only intended for training purposes, and is not safe for IV administration.

The FDA report estimates 45 patients received this fluid intravenously,  2 became septic, requiring ICU admission.  Within all of the documented incidents, 2 patients died, though the direct link to the fluid administration has not been confirmed.  The FDA sent out a safety alert and continues monitoring.


Active shooter drill causes lockdown of medical center

During an active shooter drill at a a military medical center, an alert was accidentally sent without indicating that it was a drill.   This inadvertent notification triggered a full police response, lockdown of the center, and evacuation of patients.  Many messages were posted on social media by people while they sheltered in place. Fortunately there were no physical injuries, but it was a frightening experience for all involved.



Mannikin mistaken for real person

Police were called and broke into an automobile by smashing its windows when it was reported by a neighbor that an elderly woman had been left in the front seat of the car overnight in freezing temperatures.  Police believed that the person, actually a simulation mannequin, had frozen to death.  It turned out that the automobile and mannequin belonged to a simulation equipment sales person who thought it was cool to transport his mannequin in the front seat of his car.

Middle School student injected himself with epinephrine

A health class about allergies and emergency response included instruction and demonstration of epinephrine auto – injectors. A real epinephrine injector was mixed in with the training devices, and an eleven year old student injected himself with the real drug. He was transported to a local hospital and was expected to make a full recovery.


Incidents Reported to the Foundation for Healthcare Simulation Safety

These incidents were shared with us by simulation professionals.  We maintain confidentiality of the persons and institutions, and we thank them for allowing us to use these case examples on our website.  We hope that these stories will help to increase awareness of potential hazards.

Course participants stealing simulated medications

A simulation center director reported to us that his center manager caught a group of course participant EMS providers on video, taking refilled medication vials from the simulated crash cart and putting them into their supply bags.  Apparently, they thought the medications were real and were stocking their supplies.  The individuals were confronted before this came to any harm to patients.

Real medications substituted with water by a participant

A anesthesiologist trainee participant in an in-situ simulation setting where the simulation staff had decided to use only real medications for safety reasons, reported that she had replaced all of the medications with water filled syringes while setting up for her case because she thought it was wasteful to use the real drugs.  She had not imagined the accident potential of this and took no precautions to encumber the syringes after the simulation.  The simulation staff was unaware that this substitution had been made.

Course participant administered epinephrine to himself

During a simulation of an anaphylaxis in a non-hospital setting, one of the physician course participants took an epi-pen and attempted to administer treatment to a mannequin.  Unfortunately, he held the epi-pen backwards in his hand and accidentally administered the epinephrine to a finger joint.  As this could lead to exsanguination of the joint, he was sent to the emergency room as a precaution.  No complications ensued.

Evacuation of an operating room

A course participant dialed the hospital operator during a fire safety simulation and reported a fire in the operating room.  The participants had been instructed to not to call the real operator; they were to use the simulation phone number which was posted on the phone. The stress of the scenario caused the person to forget those instructions. The person gave the phone operator an actual operating room number in the hospital, thinking she was supposed to make something up.  The operator instituted the appropriate fire protocol enlisting the fire department and evacuation of an OR, which fortunately happened to not have a case in progress at the time.

Simulated Patient Entered into Electronic Hospital Record System

An in-situ simulation (pediatric emergency room) led to 18 hours of intense work to remove a mannequin patient from the Electronic Medical Record System (EHR) when an admitting clerk thought she was supposed to do so for the simulation.  The simulation team tried to inform everyone who could possibly be involved of their roles and constraints, but inadvertently left the clerk out of the loop.

Real Code Team Called

This incident is one of many of this genre reported to us.  In this case, the simulated resuscitation was occurring at a simulation center in an adjacent building to the hospital.  Unbeknownst to the simulation staff, the phone in the room had a tie-line connection to the main hospital, so that when one of the participants dialed the appropriate number, the real code team was called.  The participant, a new orientee, actually made up a real location within the hospital when calling.  The team arrived to a patient room, only to find there was no emergency, thereby making them unavailable for a concurrent real event should it have occurred.  It took considerable sleuthing to figure out what had happened!

Simulation Instructor/ Clinician call for help disbelieved

A busy Obstetrician and Simulation Medical Director (OB/Sim) was managing the labor floor.  A high-risk patient was hemodynamically unstable and required an urgent Cesarean delivery.  During transport to the OR, another patient arrived from an outlying hospital with severe abdominal pain. A bedside ultrasound suggested a spontaneous uterine rupture, a very rare obstetrical critical event.Quite appropriately, the OB/Sim phoned up to the antenatal clinic floor, knowing another senior colleague would be there to help.

OB/Sim: “Hi Dr Collins * (name changed), I need your help urgently, I have a woman with a massive abruption and another one who likely has a spontaneous uterine rupture at 27 weeks.  The first one is anesthetized now, can you come down and help with the rupture?”

Dr Collins: “But I’m in clinic and there are only 2 of us here”

OB/Sim: “Yes I know that, but this is an emergency”

Dr Collins: “are you REALLY saying you want ME to come down and leave the other doctor here by themselves?”

OB/Sim:  “YES!!!!”

Dr Collins: (groaning) Oh, okay then

OB/Sim: thinking: incredulous!!

Dr Collins meandered slowly, expecting to find a simulation running.  He was mortified to find a real patient, who he took to the OR and who did in fact have a ruptured uterus.  The patient and newborn both did well after emergency treatment.

OB/Sim states that she will always preface urgent calls for help with “THIS IS NOT A SIMULATION”.

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