Suzanne M. Wright, PhD and Michael D. Fallacaro, DNS discuss their program to enhance patient safety – through crisis resource team training.

Project Director Suzanne M. Wright, PhD, in the simulation control room. (Photo: Virginia Commonwealth University)
Project Director Suzanne M. Wright, PhD, in the simulation control room. (Photo: Virginia Commonwealth University)

Suzanne M. Wright, PhD and Michael D. Fallacaro, DNS describe one effort to prepare surgical teams for managing an unexpected crisis and enhance patient safety.

With the advent of new technology, therapeutics and management techniques, anesthesia and surgery are safer today than perhaps at any point in history. Most patients enjoy favorable post-operative outcomes and are able to resume their personal and professional lives shortly after surgery. Evidence exists however, that despite the multitude of success stories, patients can still experience unexpected and unintentional harm when they come to the hospital for surgery.1

A low incidence of unfavorable outcomes can lead providers into a sense of false security and complacency. While anesthetic and surgical complications rarely occur, they can prove catastrophic. The challenge of preparing surgical teams for managing an unexpected crisis can be a daunting one. The rare occurrence of such untoward events offers limited opportunities to learn to manage these situations effectively. Crisis resource team training employing state-of-the-art high fidelity simulation technology has been shown effective in improving human performance in times of crisis .2


Beginning in 2013, faculty from the Center for Research in Human Simulation in the Department of Nurse Anesthesia at Virginia Commonwealth University (VCU) established a partnership with three distinct but related organizations to conduct a first of its kind crisis resource team training program in the central Virginia region. The “Growing a Culture of Safety” project was conducted over a 12 month period and comprised two half-day, hands-on workshops. The partnering groups consisted of Advanced Orthopaedics, Total Anesthesia, and The Doctors Company.

AOC team members responding to a simulated crisis within their own operating room.
AOC team members responding to a simulated crisis within their own operating room. (Photo: Virginia Commonwealth University)

The priority of the Department of Nurse Anesthesia at VCU is the education and training of Certified Registered Nurse Anesthetists (CRNAs) offering both masters and doctoral degrees in this specialty. The department’s research mission is to improve patient safety through clinical inquiry, innovations in education, the study of adverse events, and performance improvement.

Advanced Orthopaedics is a physician-owned, orthopaedic surgery practice located in Richmond, Virginia. Their practice includes “Centers of Excellence” for hand surgery, foot and ankle, joint replacement, sports medicine, spine surgery, pain management, shoulder and cartilage restoration, and physical therapy. The Advanced Orthopaedics Center (AOC) is home to three operating suites along with a dedicated special procedures room and served as the setting for this community project.

Total Anesthesia is an anesthesiologist owned group of 21 physicians and over 40 CRNAs providing anesthesia services in the anesthesia care team model to three Richmond area hospitals and several surgery centers including the AOC. Total Anesthesia administers anesthesia services to over 25,000 patients each year.

The Doctors Company is a medical malpractice insurance company headquartered in Napa, California and is among the largest physician-owned medical malpractice insurers in the United States with over 74,000 insured nationwide. This company provides malpractice coverage for practitioners at the AOC.


The purpose of this program was to explore the feasibility of a community-based, team training program designed to promote effective and reliable performance among surgical and anesthesia team members under high levels of workload and stress. The project incorporated lecture, observation, hands-on high-fidelity simulation training, and debriefing aimed at conveying knowledge of the impact of a stressful environment, emphasizing teamwork development, and building confidence in the ability to perform under high stress and critical circumstances.


The project was designed to explore the feasibility of bringing a simulation-based program out into a community-based operating room environment, where otherwise, VCU faculty engage in training in their state of the art Center for Research in Human Simulation. One proposed advantage of taking the program out into the community included improved access to training; often trainees are reluctant to travel into the city given issues related to parking, traffic, highway travel, and the complexity of the landscape. Another advantage of taking the program out into the community included enhanced fidelity of the operating room environment. While the Center for Research in Human Simulation is well-equipped with current operating room equipment and supplies, it could not possibly reach the level of fidelity of the true operating room environment in which trainees work every day.

Anticipated challenges of bringing a simulation-based team training session out into the community included scenario design issues. For example, at the Center for Research in Human Simulation, faculty usually train anesthesia providers rather than whole teams. When training anesthesia providers, faculty use simulated surgeons and circulating nurses as ‘plants’ to keep the scenarios running along and to direct the learner down a predetermined path. New challenges arise when training entire teams where real surgeons and real circulating nurses are among the trainees. In essence, the scenario can unfold in unexpected ways which could be detrimental to training objectives. To overcome this obstacle and to retain control over the educational experience, we used an orthopaedic supply salesperson as the “plant”. The ‘plant’ wore the earpiece of a two-way radio system and could follow the instructions of the scenario driver to keep the educational objectives within reach.

Another scenario design issue included the absence of high fidelity simulated surgical experiences for the surgeons. To address this shortcoming, faculty were careful to design scenarios where the crisis occurred either after induction of anesthesia but before surgical incision or after the surgical incision had been closed but before emergence from anesthesia. The ‘plant’ played an important role here. In case of a delay in the recognition of the critical event, the ‘plant’ could distract the surgeon to keep him from making an incision or from leaving the room, respectively.

The Environment

Group photo of the interprofessional team of learners at the AOC Richmond, Virginia. (Photo: Virginia Commonwealth University)
Group photo of the interprofessional team of learners at the AOC Richmond, Virginia. (Photo: Virginia Commonwealth University)

The physical space for training at the AOC included two standard operating rooms which sandwiched a small (100 sq ft) control room. Training occurred in one fully functional operating room and the other operating room was set up for observation with 40 chairs, a projection screen and projector, a duplicate patient monitor, and a podium with a laptop. The lectures were delivered in the observation room and during the training session observing participants could see and hear the training session in real time while viewing the duplicate patient monitor which may otherwise be difficult to see on the projection screen. The audio-visual equipment also allowed for video playback of the training session during debriefing.

The Curriculum

The curriculum was designed to incorporate Salas’s eight essential guidelines of simulation-based team training .3

Guideline 1, Understand the Training Needs: Prior to conducting the project, four meetings with all stakeholders were held to assess individual and group needs. A summary document was produced capturing these needs. Based on this work, the VCU team set out to design the program to highlight the essential characteristics of well-coordinated teams to include: - the ability to adapt to a changing environment, - open and flexible communication and - awareness and understanding of other team members’ workload and performance.

Guideline 2, Instructional Features, such as Performance Measures and Feedback: The VCU team established four simulation-based training scenarios each containing “trigger” events to elicit specific behaviors from learners to best meet the defined training needs. These were:

- Malignant Hyperthermia Crisis;

- Fire in the Operating Suite;

- Intraoperative MI and

- Anaphylaxis

Employing a Laerdal™ SimMan full body human patient simulator and high definition Tandberg™ video recording technology, learner performances were captured for systematic observation. In total, over 40 participants including surgeons, anesthesiologists, CRNAs, registered nurses, scrub and surgical technicians as well as AOC administrators and Doctors Company representatives took part in this training. Surgical teams were assigned to cases per normal AOC operating procedures and were unaware of the critical events ahead of time.

Guideline 3, Craft Scenarios Based on Guidance from Learning Outcomes: Learner outcomes were first established and scenarios were designed to illicit and systematically capture these embedded targeted behaviors. Upon completion of the program, it was anticipated that learners would be able to: 1) identify when a situation becomes critical; 2) understand the negative impact of stress on performance; 3) communicate more effectively under high stress conditions; and 4) work more effectively as part of a team managing a critical event. The simulation scenarios were developed keeping content-validity in mind and as such were built around surgical procedures commonly performed at the AOC.

Guideline 4, Create Opportunities for Assessing and Diagnosing Individual and/or Team Performance Within the Simulation: The “Growing a Culture of Safety” project was designed to focus on assessing team performance and efforts were made by faculty to minimize, if not completely eliminate, diagnosing individual performance. This was done purposely to encourage participation and to avoid public scrutiny of any individual(s). Immediately following these intense scenarios, sensitive debriefings were conducted by faculty employing time stamped audio-video playback features designed within the Laerdal™ simulator software package. Observers not participating in actual hands-on portion of the training were asked to complete an observer worksheet (while watching the live training session) which highlighted characteristics of effective teamwork, and engaged by faculty during the debriefing to share their thoughts and real world experiences related to the simulated events.

Guideline 5, Guide the Learning: Educational objectives laid the foundation for scenario development and three highly experienced nurse anesthesia educators were involved to guide learning in an effort to encourage positive team performance. Otherwise, simulation has the potential to destroy confidence and divide teams into dysfunctional units.

Prior to engaging learners in scenarios, faculty presented lecture content on effective teamwork and communication, the impact of stress on performance and current threats to patient safety. This content was later reinforced again during the post-scenario debriefings.

Guideline 6, Focus on Cognitive / Psychological Simulation Fidelity: Research has suggested that if psychological fidelity is high, even if environmental fidelity is less than perfect, effective learning will still take place.4 While the VCU team made significant efforts to have the highest physical fidelity of the environment represented in their simulations, current limits in technology prevent an exact replication of the real world. That said, the team worked diligently to sustain a high level of cognitive validity by drawing on real world examples and soliciting actual learner like experiences when designing and debriefing the training scenarios.

Guideline 7, Form a Mutual Partnership Between Subject Matter Experts and Learning Experts: The interprofessional team engaged in this project consisted of physicians, nurses, allied health professionals, educators, administrators and policy makers. This community of colleagues established this program with one prime purpose; to promote a culture of patient safety through thoughtful and effective collaboration.

Guideline 8, Ensure that the Training Program Worked: Program objectives were measured by participant self-assessment on an 8-question program evaluation tool scored using a 5 point Likert scale. Questions included whether the program met the stated objectives: improved participant understanding of teamwork, effective communications, and resource management and improved understanding of the negative impact of stress on performance.

Project faculty are pleased to report, taken in aggregate, 97% (n=68) of participants answered all questions with a 5, “Strongly Agree,” response. Only 3% (n=2) of respondents rated questions below a 5 and none rated any question below a score of 4, “Agree.” In addition to scoring the evaluation, many positive comments were received giving faculty insight to planning future CRM training programs for the AOC.

Conclusion Simulation provides an opportunity to teach material that cannot be taught as effectively in any other conventional manner. Individual task performance can be enhanced through simulation training. But does team training translate into improved “real world” individual or team performance in crises? While it may be possible to improve teamwork in a simulated environment, the gold standard for proving the benefit of team training is through an assessment of whether projects such as the one described in this article improve actual patient outcomes. To make such an assessment is extremely difficult if not impossible because of the large number of confounding variables (e.g., surgical techniques, individual patient and provider characteristics, surgical complications) and the fact that such serious crisis events as those presented in this program are extremely rare. Some of those investigating simulator-based training do not believe that such a study of patient outcome is logistically feasible .5 However, determining the impact of crisis resource team training on the intermediate variables of performance and ability is feasible in principle and worth the time and energy to pursue them just the same.

Developing such complex behaviors such as those required to work effectively in teams requires more than a one or two time simulation training exercise. These behaviors grow over time by continued practice and reinforcement. Additionally, individuals must be immersed in a workplace whose organizational leadership embraces a true teamwork mentality for any positive effect on outcomes to be realized.

As a result of this project, the AOC has now established a daily Emergency Response Team whereby individual staff members are assigned each day to specific roles and responsibilities should a crisis occur. Also, the AOC has revised its policies with regards to the management of malignant hyperthermia and fire in the operating room. Similarly, staff at the AOC are in the process of designing a separate Anaphylaxis Response Kit containing the necessary medications to treat this rare condition.

Faculty at VCU believe that the true value of crisis resource team training as it translates to clinical performance lies in the learner’s lived experience. The “Growing a Culture of Safety” project model provides an opportunity for interprofessional team training with high physical and psychological fidelity that promotes and supports a positive culture of patient safety.


1 National Research Council. Crossing the Quality Chasm: A New Health System for the 21st Century.                       Washington, DC: The National Academies Press, 2001.

2 Salas, E., & Cannon-Bowers, J. Decision-making under stress: Implications for individual and team training. American Psychological Association, 2000.

3 Salas, E., Wilson, KA, Burke, CS, and Priest HA.: Using simulation-based training to improve patient safety: what does it take? Joint Commission Journal on Quality and Patient Safety, 31(7):363-71, July 2005.

4 Bowers, CA., Jentsh, F.: Use of commercial, off the shelf simulations for team research. In: Salas E. (ed.): Advances in Human Performance, Vol. 1. Amsterdam: Elsevier Science, 2001, pp. 293-317.

5 Gaba, DM., Howard, SK., Fish, KJ., Smith, BE., Sowb, YA.: Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation and Gaming, 32(2):175-93, June 2001.

About the Authors

Suzanne M. Wright, CRNA, PhD., is Associate Professor and Vice Chair for Academic Affairs in the Department of Nurse Anesthesia at Virginia Commonwealth University. She also serves as Director of the Department’s Center for Research in Human Simulation where she focuses her research on human factors as they influence performance in clinical settings.

Michael D. Fallacaro, CRNA, DNS, is Professor and Chair of the Department of Nurse Anesthesia, School of Allied Health Professions at Virginia Commonwealth University. Dr. Fallacaro also founded the Department’s “Center for Research in Human Simulation” in 1998.