Various mitigation strategies have been used to lessen the risks of simulation.  The following are contributed from our community.


Lisa Resch BSN RN CHSE

Clinical Simulation Coordinator

Aurora BayCare Medical Center

Simulation is a tool we use to improve patient safety, it is imperative we do everything possible within our programs to eliminate inadvertent harm, to both patient’s and simulation participants.

The realization that nothing could cause the demise of a program faster than a patient being harmed or, by participants being injured during simulation, prompted me to take a pro-active approach to prevent such an occurrence.

These are simple, inexpensive things we have adapted for maintaining safety and reducing risk in simulation:

  • Simulated blood and medications are colored and labeled with a “NOT FOR HUMAN USE-Education Only “sticker.  These stickers can be made or purchased through the Foundation for Healthcare Simulation Safety ( website; there is a small fee to cover the printing of the stickers.  Our simulated blood and medications are colored green, it is an important part of the pre-brief to remind participants that “as a safety precaution, we color simulated medications and blood green to distinguish them as simulated and remind you to never use these items outside the simulated environment.”
  • We purchased a crash cart to use for mock codes, we wanted the exact cart we use throughout the facility and we wanted it stocked exactly the same as the real crash carts.  All of the crash carts are red so before stocking and putting the cart in use it was painted green and labeled NOT FOR PATIENT USE-EDUCATION ONLY”.  When the cart is not in use it is always locked in a simulation storage closet that only the simulation faculty have access to.  The simulation crash cart is never left in a unit or unattended between simulations to prevent it from accidently being brought to a code.
  • Many of the items we use in our simulation program are from expired unit stock.  To prevent participants from possibly thinking expired items are okay to use because they used them in simulation, we cover the expiration date with a sticker, the date on the package is blacked out first to prevent being able to see it through the sticker, the stickers are labeled with a date well into the future: EXPIRATION DATE 01/2135, for example.
  • When reusing kits or trays, once open, the individual items in the tray are stickered with the “NOT FOR HUMAN USE” stickers so that if any items are separated from the kit, they won’t accidently be used.  The kits are then sealed with a “NOT FOR HUMAN USE” sticker and can be used again.
  • In-situ simulation programs allow participants to train, locate and utilize equipment in their work environment, yet we don’t want open a new kit or disposable items for each simulation, this can be costly (tubing for a Belmont Rapid Infuser is over $ 300 a set). In keeping with the realism contract, we want participants to find the equipment they need for a patient care scenario, a trauma for example, we have them find the equipment and give it to the facilitator who in turn takes the kit and exchanges it for a kit that has been marked for education that they can open and set up.
  • It is important to be sure that no simulation equipment is left in a patient room after the scenario is complete. Utilizing a checklist, or a “sponge count” like they use in surgery, in the scenario planner allows the facilitator(s) to account for all simulated items used in the scenario.  Once the debriefing is complete, we ask all participants to check their pockets for any simulated items they may have used.  Facilitators should work together to complete their “sponge count” and make sure all simulated items are returned and accounted for.
  • In our program, pre-briefing begins about two weeks ahead of the simulation with a pre-course email. The email contains information about the capabilities of the simulator, where the simulation will be located and sets expectations of the participants.  One of the requirements for simulation attendance is to wear scrubs, no open toed shoes and no street clothes.  In the pre-course letter we outline that simulated body fluids may soil clothing and could cause the floor to be wet therefore appropriate clothing must be worn.  Participants that arrive in street clothes are not allowed to attend unless there is time for them to change, we will not delay the start for them.
  • The pre-course email and pre-brief also remind participants they must utilize safe lifting equipment and proper body mechanics if they need to move the simulator.  We are careful to make sure we have hover mats, Patran sheets, and other items we would require staff to use when moving or repositioning patients in their units.  It is imperative we keep participants safe; falls, needle sticks, etc. that could lead to worker’s compensation claims and/or lost time injuries could be detrimental to simulation programs.
  • If there are unsafe behaviors during the simulation they are addressed in the simulation they must be addressed.  Unsafe behaviors that are not addressed may be perceived as acceptable by the participants; recapping needles, no hand hygiene, failure to correctly identify the patient, etc. all must be addressed during debriefing.
  • We also do not allow participants to perform any skill or intervention in simulation that they are not licensed to do or is not within their scope of practice.  If someone is not able to intubate, administer medications, etc. in their practice, they cannot be allowed to do so in simulation.
  • When simulation is done in-situ, it is important to take into consideration the emotional safety patients, visitors, and staff in the unit where a simulation is being done.  The realism of simulated events could upset a patient or visitor if they did not know it was simulation, we post large laminated posters outside simulation rooms that read “Staff Simulation Education in Progress.”  We also talk to the unit staff in the morning during bed huddle to let them know there is simulation being done in the unit that day, they will let their patients and visitors know there is simulation being done in the unit.  While we keep the door to the room closed during a simulation, we leave the door open while setting up the simulation.  We have found that patients and visitors will watch the set up and many times ask questions about simulation and why we do it, this is a great opportunity to market your program.  People are curious and they find it impressive that hospitals invest in not only staff education but patient safety with this type of technology; we have even seen positive comments on patient satisfaction surveys.