Ali Alkhulaif, MD, Ian Julie, MD, Joseph Barton, MD, MHMS, FACEP, Erin Nagle, Pharm D, BCPS, and Aubrey Yao, MD discuss how interdisciplinary team in situ simulation in a real patient care setting is a valuable tool to identify needs and to promote effective communication, technical skills and process improvement in a complex, high-risk environment.

Since the release of the Institute of Medicine’s landmark report, “To Err is Human: Building a Safer Health System,” there has been an increased focus on reducing iatrogenic injuries and errors in patient care (IOM 2000). Medical simulation has been increasingly recognized as a modality that can be used to reduce medical errors in a variety of care settings and with varying degrees of realism. Recent advances in simulator and wireless technology provide further opportunities to take this training directly into the work environment, hereafter referred to as in situ simulation, which is defined as simulation-based training that occurs in a clinical environment with participants who are on-duty (Patterson 2008). In this article we discuss the advantages, challenges and obstacles for implementing in situ simulation in a tertiary care hospital.


Real time work constraints force in situ simulation objectives to be more focused than they might be in a simulation laboratory setting. While simulation in a designated simulation lab is useful for developing both technical and non-technical skills, in situ simulation can also be used to expose and analyze barriers to implementation of those skills in the patient environment. Some examples of obstacles that can easily be identified in situ are: errors in the understanding or implementation of protocols, limitations imposed by the physical environment, and problems with communication between colleagues.

For instance, practitioners may rehearse a cardiac arrest scenario in the simulation lab to learn or practice fundamental technical skills such as defibrillator use or CPR. When practicing in an actual work environment, new dimensions of the same skills (such as difficulty finding/applying/connecting the defibrillator or difficulty providing quality chest compressions on a hospital bed) may appear. In this manner, in situ simulation can help to uncover system-level issues and can be used as part of a continuous quality improvement program for patient care.

In situ simulation can be used to train an individual or even an entire healthcare team to perform infrequent (yet critical) tasks, use new or seldom needed equipment, and to implement or practice hospital protocols. Thus, in situ simulation can be used as a tool to identify both gaps in training and areas for improvement (Kobayashi 2006).

Additionally, an in situ simulation program can be created in a cost effective manner. There is no need for an expensive simulation center, apart from physical storage space for the mannequin and related equipment. Additional compensation for training time can be reduced if the training can occur during work hours. Furthermore, in situ simulation is a highly visible way to present medical simulation training to health system leadership. This training can demonstrate the potential return on investment for staff training and patient safety before investing in a full simulation center or division.

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Hospital mock code blue debriefing outlines (page one and two).
Hospital mock code blue debriefing outlines (page one and two).


Creating an in situ simulation program can pose challenges that are technical, administrative, logistical, cultural and financial. Fortunately, effective planning and good communication can overcome most of these obstacles.

Occupying a patient care space while removing active clinical staff from patient care has the potential to result in delays in care or other harm to real patients. The team must always balance the risk versus the benefit of training in real time. There should be a low threshold to reschedule or cancel in situ training due to unit overcrowding, understaffing, or actual emergencies.

Logistical issues are particularly complex in high acuity units, such as the Emergency Department or ICU, and can also occur during hospital-wide patient surges. Facilitators should communicate early and often with administrative personnel to confirm the feasibility of running the simulation exercise. The team must also be flexible with training locations (e.g. using a break room or a less traveled hallway instead of a patient room). In our experience, increased realism can still be maintained in a number of these non-traditional hospital areas and room settings, despite physical space limitations. Establishing these parameters with hospital leadership, particularly nursing leadership, is essential to success.

Timing of the event is a fundamental aspect of a successful in situ simulation program. For our in-hospital mock codes, our goal is to be in and out of the unit within 30 minutes. This time includes set up, briefing of the primary responder to basic mannequin functions, running the scenario and debriefing. Equipment setup and removal takes approximately 10 minutes. The scenarios are standardized and pre-programmed to last for 10 minutes. Two faculty physician members of the simulation team perform a 10-minute debriefing with a standardized checklist: one reviews technical skills and the other emphasizes crisis resource management skills (Figure 1a, 1b). Since such a short debriefing session may be insufficient for some participants, we follow this with a standardized email to participants that contain both a written summary and 2-3 minutes of video debriefing (Figure 2a, 2b). This asynchronous highlight reel and 2-3 minutes of video debriefing with notes for improvement is created and released within 48 hours of the session using standard (and free) video editing software. It is likewise important to include multiple hospital shifts in planning (day and night) to achieve further saturation of training efforts, while also balancing the involvement of simulation staff and faculty.

In situ simulation training usually requires the use of hospital equipment and medical supplies. The use of existing unit supplies can help to identify obstacles that may be present during real events (such as equipment/medication availability, accessibility, difficulties with administration, dosing, etc.) but can easily and quickly add significant costs to an ongoing in situ training program. A more cost effective approach is to use expired or mock supplies similar to the actual medications in the unit. We employ a mock code crash cart containing expired and artificial drug replicas with similar packaging. This practice is effective and popular, but caution must be taken so that these supplies are not inadvertently used for actual patient care! All of our artificial drugs and our mock crash cart are conspicuously labeled and processed separately to reduce the likelihood of error. Charges are absorbed through our hospital training budget and our pharmacy staff is intimately involved in the process of evaluating the use of the cart for best practice.

The amount of work technical personnel must provide for an effective in situ simulation experience (including transport and setup of equipment, running simulations, debriefing and clean up) should not be underestimated. Our experience demonstrates the value of having an interdisciplinary team to help distribute the workload. This team is comprised of clinical staff from different departments - nursing, pharmacy, respiratory therapy and physicians of various disciplines. Our key to success was the development of a team approach that provides opportunities for input and responsibility from all stakeholders. Equipment storage near to target units and having a dedicated gurney to transport the mannequin makes moving the equipment easier. Checklists of required equipment reduce the risk of loss or forgetting necessary supplies. Scheduling events at least three months out can help simulation personnel ensure sufficient staffing and can smooth out hospital ward availability and saturation. We have chosen late morning and late night training to avoid medication administration times, meal times, and morning physician rounds.

Simulation exercises are intimidating to some participants. Mistakes may be made in front of colleagues and even supervisors. Being recorded during the simulation adds stress, particularly if the participant does not understand the purpose of the recorded video. The simulation team should develop a consent process related to in situ simulations and clearly communicate the intended objectives to learners. Trust must be established between the simulation team and the participants. Any violation of how videos are used or whether participants are judged based on their simulation performance could endanger the fundamental principles of “safe learning.” If any research is to be done with associated data, Institutional Review Board approval is a must.

Finally, clear goals must be evaluated and maintained or revised accordingly throughout the process. Sharing data about the potential impact on patient safety goals with hospital leadership and participants can further motivate learners and increase buy-in. In situ simulations can make existing challenges more visible and help all participants develop and apply new strategies for problem solving.

Our Experience

Practitioners with different backgrounds assemble to form a Code Blue team and provide in-hospital cardiac arrest care at our facility. Nurses from the unit initiate the code. Nearby physicians typically join in the effort and are followed by a dedicated group of ICU nurses and resident physicians from on-call teams. Often these practitioners do not know each other, yet these personnel are expected to communicate, coordinate and cooperate as a single, cohesive unit. Good protocols, communication skills and teamwork behaviors are critical to success. In situ mock Code Blue events help us to practice this process and identify areas for improvement. Providers practice skills in a safe and controlled environment, including chest compressions, basic/advanced airway management, medication administration, and defibrillation technique. It is important to recognize that a frequent source of error is related to communication (Rothschild 2005, Donchin 2003). Hence, behavior such as calling for help early, identifying a team leader, having members announce their arrival, utilizing closed loop communication, and distributing the work optimally are observed and are reinforced during the debriefing process.

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iN situ figure 2b (2)
Screen shots of the asynchronous video debriefing for hospital mock code blue. Image Credit: UC Davis Health System Mock Code Blue Team.

Between August 2012 and December 2013, we conducted a total of 32 simulated cardiopulmonary arrest codes. These involved groups numbering between 6 and 20 interdisciplinary participants.

We recorded and tracked compression fraction (the proportion of time that chest compressions were on-going during periods of pulselessness), average time to epinephrine administration and the average number of CPR interruptions in each event. We have noted trends toward improvement in units where our mock codes have occurred more frequently and have continued the codes throughout 2014 (our data is currently pending publication). Most importantly, we have identified clear opportunities for improvement in the overall organization of code management in our hospital system.

In situ simulation has given us a window into the potential challenges and opportunities facing our current model of inpatient medical care. The data we have acquired has helped us to identify actionable areas of improvement with our health system leadership and risk management office. Our experience demonstrates that in situ simulation with interdisciplinary participation in a real patient care setting is a valuable tool to identify needs and to promote effective communication, technical skills and process improvement in a complex and high-risk environment.

About the Authors

All authors are affiliated with the University of California, Davis Health System and are members of the Mock Code Blue Training Team.

- Ali Alkhulaif, MD, International Scholar, Medical Simulation Fellow, Center for Virtual Care.

- Ian Julie, MD, Medical Simulation Fellow, Department of Emergency Medicine.

- Joseph Barton, MD, MHMS, FACEP, Assistant Clinical Professor, Department of Emergency Medicine, Director of Medical Simulation Fellowship & Medical Director of UCDHS Clinical Documentation Improvement.

- Erin Nagle, Pharm D, BCPS, Clinical Pharmacist.

- Aubrey Yao, MD, Assistant Clinical Professor, Department of Anesthesiology and Pain Medicine, Director of Cardiovascular Anesthesiology Fellowship.

Other code blue team members are Samuel Clarke, MD, Assistant Professor, Department of Emergency Medicine; Sandhya Venugopal, MD, FACC; William Hammontree, RN, BSN, Program Manager, Center for Virtual Care; Jose Ramirez, Simulation Specialist; Karrin Dunbar, RN, BSN, Nurse Educator; Christian Sebat, DO, Assistant Clinical Professor; and Aaron Bair, MD, MS, Professor of Emergency Medicine, Medical Director, Associate Dean, Continuing Medical Education.


  1. Institute of Medicine Committee on Quality of Health Care in America. In: Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US). Copyright 2000 by the National Academy of Sciences. All rights reserved; 2000.
  1. Patterson MD, Blike GT, Nadkarni VM. Advances in Patient Safety. In Situ Simulation: Challenges and Results. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.
  1. Kobayashi L, Shapiro MJ, Sucov A, Woolard R, Boss RM, 3rd, Dunbar J, et al. Portable Advanced Medical Simulation for New Emergency Department Testing and Orientation. Academic Emergency Medicine. 2006; 13(6): 691-5.
  1. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, et al. The Critical Care Safety Study: The Incidence and Nature of Adverse Events and Serious Medical Errors in Intensive Care. Critical Care Medicine. 2005; 33(8): 1694-700.
  1. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, et al. A Look into the Nature and Causes of Human Errors in the Intensive Care Unit. 1995. Quality & Safety in Health Care. 2003;12(2): 143-7; discussion 7-8.