Simulation and the Science of Learning from a 'Safe Mistake'
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Simulation and the Science of Learning from a 'Safe Mistake'

By Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality

Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality

Everyone makes mistakes. It’s the nature of being human. But in our line of work, mistakes can be deadly. The complex, high-risk nature of health care, like that of commercial aviation and oil and gas exploration and extraction, creates significant opportunity for error—the consequences of which can be grave. This is why the prospect of making a “safe mistake” and learning from it without causing actual harm is so appealing.

"Simulation is promising because it offers a range of customizable, easily accessible learning opportunities"

Health care simulation is used in medical education and patient safety improvement programs to create a safe learning environment for clinicians to train, enhance skills, and test new processes before encountering patients.

The concept is not new to our field. We’ve used training manikins such as Resusci Anne, which were initially crude but effective forerunners to current simulated systems, for decades to practice CPR, venipuncture, and other procedures. As technology advanced, so did simulation. (Resusci Anne today is an advanced model that addresses a variety of procedures and scenarios.) The Society for Simulation in Healthcare (SSH) was founded 14 years ago, in 2004, to advance health care simulation, and the Agency for Healthcare Research and Quality (AHRQ) was a supporter of simulation research programs from the outset.

But the concept is gaining new traction in health care as we come to appreciate how simulation has improved safety in other high-risk settings. Simulation programs have spread across the health care system, including hospitals, other settings where care is provided, and medical and nursing schools.

Simulation is promising because it offers a range of customizable, easily accessible learning opportunities. It also offers a highly standardized and controlled environment where researchers can answer the tough questions that may be difficult to study in real-world medical environments.

AHRQ, as the nation’s lead federal agency for advancing patient safety research, recognized simulation’s potential to improve the safety of health care more than a decade ago. AHRQ’s support began with a 2006 grant that evaluated the use and effectiveness of various simulation approaches, and a series of projects continues this important work. Today, AHRQ funds projects that are showing measurable success, such as one that found that assessing anesthesiologists’ skills in simulated medical emergencies can help identify opportunities for improvement and inform continuing medical education. Another example: in an AHRQ Patient Safety Learning Laboratory, a project uses simulation technology to support safer care for mothers and their babies before, during, and after delivery. To further understanding, AHRQ partnered with colleagues at SSH to publish a Healthcare Simulation Dictionary.

Like every field of study within health care, simulation must be held to rigorous standards to ensure we are deriving as much as we can from it. As health care simulation has matured, reasonable questions have emerged about how to realize its full value. Basic questions include:

• Are the safety and quality of care to patients actually improved by simulation?

• Is something new being learned regarding the optimal use of simulation?

• How are skill acquisition, maintenance, and progression managed in the contexts of simulation and practice in general?

Concerns focus on pursuing the right research questions to learn about the optimal use of simulation; doing more with simulation than simply providing an interesting educational experience; and encouraging all participants—including investigators, funders, and reviewers—to expand their vision regarding what constitutes important inquiry and evidence.

It boils down to this essential question: we can offer the opportunity for consequence-free mistakes, but how can we make sure that we’re actually learning from them?

We at AHRQ welcome these questions, because simulation ought to be judged according to the standards applied to other medical education and patient safety interventions. We recognize that it takes time for any new approach to gain momentum and learn from past efforts. We also recognize that it will require addressing a range of questions to improve knowledge on the optimal use of simulation.

Nevertheless, initial results of the use of simulation over the past several years are sufficiently encouraging that we are eager to see broader uptake of simulation. We believe that it will create and deliver value to medical students and residents, practicing clinicians, and ultimately to patients in the form of safer, more efficient care.

As a significant funder of patient safety research, we welcome your ideas to use simulation to make care safer. Visit the AHRQ funding announcements page to see the latest funding opportunities.

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