Simulation- May 2012



Simulation – Monthly Update



May 2012

Welcome to the May bulletin on Simulation being produced by the HEFT Library Services. This bulletin is produced to support Simulation training carried out in the Harry Hollier Simulation Centre at Good Hope. This issue will highlight evidence published in the previous 4 weeks. Full text articles can be accessed via your HEFT Athens ID.

Human factors

Title: Human factors in resuscitation teaching

Citation: Resuscitation, April 2012, vol./is. 83/4(423-427), 0300-9572;1873-1570 (April 2012) Author(s): Norris E.M., Lockey A.S.

Abstract: The aim of this paper is to explore how human factors might be taught on resuscitation courses, and improve course outcomes in terms of improved mortality and morbidity for patients. The delivery of human factors training is important and this review explores the work that has been delivered already and areas for future research and teaching.

Full Text:Available in fulltext at Elsevier; Note: You will need to register (free of charge) with Science Direct the first time you use it.


Title: Time to accelerate integration of human factors and ergonomics in patient safety.

Citation: BMJ Quality & Safety, April 2012, vol./is. 21/4(347-51), 2044-5415;2044-5423 (2012 Apr) Author(s): Gurses AP, Ozok AA, Pronovost PJ

Abstract: This paper gives an overview of the discipline of human factors and ergonomics and describes its role in improving patient safety. The paper also provides examples of how human factors and ergonomics principles and methods have improved both care processes and patient outcomes.

Full Text:

Available in fulltext at Highwire Press


Medical errors and patient safety

Title: Evaluation of drug administration errors in a teaching hospital.

Citation: BMC Health Serv Res. 2012 Mar 12;12(1):60. [Epub ahead of print] Author(s): Berdot S, Sabatier B, Gillaizeau F, Caruba T, Prognon P, Durieux P.

ABSTRACT: Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. The authors aimed  to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors.

Full text: Available in full text via


Title: Evidence scan: Reducing prescribing errors.

Author: Health Foundation, March 2012

Abstract: Medicines can do a lot of good but they also have the potential to cause harm. Medication errors are one of the most common causes of patient harm and prescribing accounts for a large proportion of medication errors. This evidence scan examines strategies to reduce prescribing errors.

Full text: Available in full text via


Title: A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.

Citation: Lancet. 2012 Apr 7;379(9823):1310-9. Epub 2012 Feb 21.Author(s): Avery AJ, Rodgers S, Cantrill JA, Armstrong S, Cresswell K, Eden M, Elliott RA,

Howard R, Kendrick D, Morris CJ, Prescott RJ, Swanwick G, Franklin M, Putman K,

Boyd M, Sheikh A.

Abstract: Medication errors are common in primary care and are associated with considerable risk of patient harm. The study tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the  intervention.


Title: Never events

Citation: Obstetrics, Gynaecology and Reproductive Medicine, May 2012, vol./is. 22/5(135-137), 1751-7214;1879-3622 (May 2012)

Author(s): Nazeer S., Shafi M.I.


Title: Patient safety in medication; a retrospective inspection of reported errors and near misses

Citation: Bone Marrow Transplantation, April 2012, vol./is. 47/(S487), 0268-3369 (April 2012) Author(s): Stenvall M.

Abstract: This development work is part of Patient safety studies (30 ECTS) in The Patient Safety and Learning Center of Arcada in Helsinki Finland. These studies will be finished by spring 2012. Retrospective inspection of reported errors and near misses from the Hai Pro-system (9/2009-9/2011) will be done. Reporting the results of this retrospective inspection of medication errors and near misses - total number of medication errors, how these errors are divided in different subgroups, what action has already been taken and possible impact to the reported errors. It will be also discussed if new interventions are needed? Follow up after 1/2 months after intervention, which will take place in autumn 2012.


Title: The Anesthesia Patient Safety Foundation at 25: A pioneering success in safety, 25th Anniversary provokes reflection, anticipation

Citation: Anesthesia and Analgesia, April 2012, vol./is. 114/4(791-800), 0003-2999 (April 2012) Author(s): Eichhorn J.H.

Full Text:  Available in fulltext at Ovid


Title: Dangerous connections: Healthcare community tackles tubing risks

Citation: Journal of Clinical Engineering, April 2012, vol./is. 37/2(63-67), 0363-8855;1550-3275 (April-June 2012) Author(s): Vockley M.

Abstract: Tubing misconnections are "a persistent and potentially deadly occurrence" in healthcare facilities, according to The Joint Commission. This article describes the risks associated with widely used Luer connectors, a universal fitting used to connect small-bore lines and cables that pump fluids or gases into or out of patients. In the absence of clear guidance or standards, clinicians and manufacturers are using interim measures, such as risk management approaches, to prevent tubing misconnections. International working groups are developing design standards as a longer-term solution.


Title: Safety in the endoscopy suite: Lessons from the aviation industry

Citation: Frontline Gastroenterology, April 2012, vol./is. 3/2(92-93), 2041-4137;2041-4145 (April 2012) Author(s): Brown J.L.

Full Text: Available in fulltext at Highwire Press


Title: Reducing outpatient chemotherapy order errors: Using the quality improvement process to enhance patient safety

Citation: Gynecologic Oncology, March 2012, vol./is. 125/(S69-S70), 0090-8258 (March 2012) Author(s): Smith J., Spinks T., Garcia E., Levenback C.

Abstract: This research effort was sought to enhance patient safety and the overall quality of patient care outcomes in gynaecologic oncology by improving the chemotherapy order process. The primary objective was to decrease the number of gynaecologic oncology chemotherapy order set errors by 20% by July 2011.


Title: Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes.

Citation: BMJ Quality & Safety, April 2012, vol./is. 21/4(295-300), 2044-5415;2044-5423 (2012 Apr) Author(s): Mamede S, Splinter TA, van Gog T, Rikers RM, Schmidt HG

Abstract: The objective of this study was to explore the causes of faulty reasoning and the mechanisms through which reflection neutralises them by investigating the influence of salient distracting clinical features on diagnostic decision-making.

Full Text: Available in fulltext at Highwire Press

Title: Factors associated with disclosure of medical errors by housestaff.

Citation: BMJ Quality & Safety, April 2012, vol./is. 21/4(271-8), 2044-5415;2044-5423 (2012 Apr) Author(s): Kronman AC, Paasche-Orlow M, Orlander JD

Abstract: Attributes of the organisational culture of residency training programmes may impact patient safety. Training environments are complex, composed of clinical teams, residency programmes, and clinical units. The study examined the relationship between residents' perceptions of their training environment and disclosure of or apology for their worst error.

Full Text:  Available in fulltext at Highwire Press

Title: Nature and timing of incidents intercepted by the SURPASS checklist in surgical


Citation: BMJ Qual Saf. 2012 Mar 23. [Epub ahead of print]

Author(s): de Vries EN, Prins HA, Bennink MC, Neijenhuis P, van Stijn I, van Helden SH, van Putten MA, Smorenburg SM, Gouma DJ, Boermeester MA. Abstract: This study aimed to assess the number, nature and timing of incidents intercepted by use of the Surgical Patient Safety System (SURPASS) checklist, a patient-specific multidisciplinary checklist that covers the entire surgical patient pathway.

Full text: Available in full text here (Login with your Athens ID on before clicking this link).




Medical debriefing

Title: Debriefing Olympics-A Workshop Concept to Stimulate the Adaptation of Debriefings

to Learning Contexts.

Citation: Simulation in Healthcare. 2012 Apr 16. [Epub ahead of print] Author(s): Dieckmann P.

Full text: Available in Print from Harry Hollier Simulation Centre.


Simulation and medical training

Title: Stroke and TIA Assessment Training: A New Simulation-Based Approach to Teaching Acute Stroke Assessment.

Citation: Simulation in Healthcare: The Journal of The Society for Medical Simulation, April 2012, vol./is. 7/2(117-22), 1559-2332;1559-713X (2012 Apr) Author(s): Garside MJ, Rudd MP, Price CI

Abstract: The article describes a new single-day training event that uses simulated scenarios to demonstrate stroke recognition and an intravenous thrombolysis protocol.

Full text: Available in Print from Harry Hollier Simulation Centre.

Title: Pilot-Phase Findings From High-fidelity In Situ Medical Simulation Investigation of Emergency Department Procedural Sedation.

Citation: Simulation in Healthcare: The Journal of The Society for Medical Simulation, April 2012, vol./is. 7/2(81-94), 1559-2332;1559-713X (2012 Apr) Author(s): Kobayashi L, Dunbar-Viveiros JA, Devine J, Jones MS, Overly FL, Gosbee JW, Jay GD

Abstract: Emergency department procedural sedation (EDPS) is becoming widespread. Simulation may enhance patient safety through evidence-based training, effective assessment, and research of EDPS operators in pertinent knowledge, skills, processes, and teamwork.

Full text: Available in Print from Harry Hollier Simulation Centre.


Title: A multilingual audiometer simulator software for training purposes

Citation: Acta Oto-Laryngologica, April 2012, vol./is. 132/4(428-433), 0001-6489;1651-2553 (April 2012) Author(s): Kompis M., Steffen P., Caversaccio M., Brugger U., Oesch I.

Abstract: The objective was to develop a flexible audiometer simulator software as a teaching and training tool for pure tone and speech audiometry, both with and without masking. A set of algorithms, which allows a computer to determine the answers of simulated patients during pure tone and speech audiometry, is presented. Based on these algorithms, a computer program for training in audiometry was written and found to be useful for teaching purposes.


Title: A review on the relation between simulation and improvement in hospitals.

Citation: BMC Medical Informatics & Decision Making, 2012, vol./is. 12/(18), 1472-6947;1472-6947 (2012) Author(s): van Lent WA, Vanberkel P, van Harten WH

Abstract: Simulation applications on operations management in hospitals are frequently published and claim to support decision-making on operations management subjects. However, the reported implementation rates of recommendations are low and the actual impact of the changes recommended by the modeler has hardly been examined. This paper examines: 1) the execution rate of simulation study recommendations, 2) the research methods used to evaluate implementation of recommendations, 3) factors contributing to implementation, and 4) the differences regarding implementation between literature and practice. Full Text:  Available in fulltext at EBSCOhost Available in fulltext at BioMedCentral Available in fulltext at National Library of Medicine Available in fulltext at ProQuest

Title: Simulation-based education improves clinical knowledge and confidence in management of common urgent inpatient conditions

Citation: Journal of Hospital Medicine, March 2012, vol./is. 7/(S54), 1553-5592 (March 2012) Author(s): Webb B., Vucicevic D., Barr P., Mookadam F., Charles J.

Abstract: In this study, we compared simulation-based instruction to conventional lecture based didactic instruction of clinical management of common urgent hospital situations among internal medicine residents.


Title: Boot camp: Educational outcomes after 4 successive years of preparatory simulation-based training at onset of internship

Citation: Journal of Surgical Education, March 2012, vol./is. 69/2(242-248), 1931-7204;1878-7452 (March-April 2012) Author(s): Fernandez G.L., Page D.W., Coe N.P., Lee P.C., Patterson L.A., Skylizard L., St. Louis M., Amaral M.H., Wait R.B., Seymour N.E.

Abstract: To improve the clinical orientation process for new postgraduate year (PGY)-1 residents, the authors developed an intensive preparatory training curriculum inclusive of cognitive and procedural skills, training activities considered essential for early PGY-1 clinical management. The authors defined their surgical PGY-1 Boot Camp as preparatory simulation-based training implemented at the onset of internship for introduction of skills necessary for basic surgical patient problem assessment and management. This orientation process includes exposure to simulated patient care encounters and technical skills training essential to new resident education. The study reports educational results of 4 successive years of Boot Camp training.


Title: Simulation-based crisis resource management training for pediatric critical care medicine: A review for instructors

Citation: Pediatric Critical Care Medicine, March 2012, vol./is. 13/2(197-203), 1529-7535;1947-3893 (March 2012) Author(s): Cheng A., Donoghue A., Gilfoyle E., Eppich W.

Abstract: The aim of this article is to review the essential elements of crisis resource management and provide a resource for instructors by describing how to use simulation-based training to teach crisis resource management principles in pediatric acute care contexts.


Title: Developement of medical simulation training for practicing hospitalists: Fundamentals of implementation

Citation: Journal of Hospital Medicine, March 2012, vol./is. 7/(S132-S133), 1553-5592 (March 2012) Author(s): Geyer H.H., Hensley B., Cannon K., Ivanov I., Stiefeld R., Charles J.

Abstract: The purpose of the study was to design a curriculum specific to hospitalists that identifies common practices unique to the profession and pairs those practices with a specific simulation and comprehensive performance review focused on application-based skill enhancement.



Title: What should be included in a simulation course for anaesthetists? The Merseyside trainee perspective

Citation: European Journal of Anaesthesiology, March 2012, vol./is. 29/3(137-142), 0265-0215;1365-2346 (March 2012) Author(s): Mercer S.J., Moneypenny M.J., Fredy O., Guha A.

Abstract: This study is the first attempt in the UK to establish the views of senior anaesthetic trainees in relation to acquiring the attributes of an 'ideal' anaesthetist, and how these could be met by a simulation course.


Title: "This Is a Decision You Have to Make": Using Simulation to Study Prenatal


Citation: Simulation in Healthcare. 2012 May 7. [Epub ahead of print] Author(s): Boss RD, Donohue PK, Roter DL, Larson SM, Arnold RM.

Abstract: This pilot study examines how simulation might be used to engage neonatologists in reflecting on their usual prenatal counselling behaviours.

Full text: Available in Print from Harry Hollier Simulation Centre.


Team training

Title: Video review using a reliable evaluation metric improves team function in high-fidelity simulated trauma resuscitation

Citation: Journal of Surgical Education, May 2012, vol./is. 69/3(428-431), 1931-7204;1878-7452 (May-June 2012)

Author(s): Hamilton N.A., Kieninger A.N., Woodhouse J., Freeman B.D., Murray D., Klingensmith M.E.

Abstract: The aim is to demonstrate that instruction of proper team function can occur using high-fidelity simulated trauma resuscitation with video-assisted debriefing and that this process can be integrated rapidly into a standard general surgery curriculum.


Title: A crisis of faith? A review of simulation in teaching team-based, crisis management skills to surgical trainees

Citation: Journal of Surgical Education, May 2012, vol./is. 69/3(274-281), 1931-7204;1878-7452 (May-June 2012) Author(s): Doumouras A.G., Keshet I., Nathens A.B., Ahmed N., Hicks C.M.

Abstract: The purpose of this review was to appraise and summarize the design, implementation, and efficacy of peer-reviewed, simulation-based CRM training programs for postgraduate trainees (residents).


Title: High fidelity simulation based team training in urology: A preliminary interdisciplinary study of technical and nontechnical skills in laparoscopic complications management

Citation: Journal of Urology, April 2012, vol./is. 187/4(1385-1391), 0022-5347;1527-3792 (April 2012) Author(s): Lee J.Y., Mucksavage P., Canales C., McDougall E.M., Lin S.

Abstract: Simulation based team training provides an opportunity to develop interdisciplinary communication skills and address potential medical errors in a high fidelity, low stakes environment. The study evaluated the implementation of a novel simulation based team training scenario and assessed the technical and nontechnical performance of urology and anesthesiology residents.

Full Text: Available in fulltext at Elsevier; Note: You will need to register (free of charge) with Science Direct the first time you use it.



Title: Video analysis of dispatcher-rescuer teamwork-Effects on CPR technique and performance

Citation: Resuscitation, April 2012, vol./is. 83/4(494-499), 0300-9572;1873-1570 (April 2012) Author(s): Birkenes T.S., Myklebust H., Neset A., Olasveengen T.M., Kramer-Johansen J.

Abstract: The authors wanted to study the effect of continuous dispatcher communication on CPR technique and performance during 10 minutes  of simulated cardiac arrest.

Full Text: Available in fulltext at Elsevier; Note: You will need to register (free of charge) with Science Direct the first time you use it.


Title: Learning surgical communication, leadership and teamwork through simulation

Citation: Journal of Surgical Education, March 2012, vol./is. 69/2(201-207), 1931-7204;1878-7452 (March-April 2012) Author(s): Bearman M., O'Brien R., Anthony A., Civil I., Flanagan B., Jolly B., Birks D., Langcake M., Molloy E., Nestel D.

Abstract: In Australia and New Zealand, surgical trainees are expected to develop competencies across 9 domains. Although structured training is provided in several domains, there is little or no formal program for professionalism, communication, collaboration, and management and leadership. The Australian federal Department of Health and Aging funded a pilot course in simulation-based education to address these competencies for surgical trainees. This article describes the course and evaluation.


Title: A pilot project for training operative department practitioners to improve team performance with a two stage process of screen based simulation followed by simulation on airway training head

Citation: British Journal of Anaesthesia, March 2012, vol./is. 108/(ii176-ii177), 0007-0912 (March 2012) Author(s): Mukherjee K., Shah M.

Abstract: The study describes a pilot project of training newly qualified ODPs with an aim to improve team performance during failed intubation /ventilation scenario, using a two stage process to enhance cognitive retention and performance.

Full Text: Available in fulltext at EBSCOhost EJS Available in print at Solihull Staff Library


Title: The validity of simulation for team training for patient safety in anaesthesia: An observational study comparing team interactions in the operating room and the simulated environment

Citation: British Journal of Anaesthesia, March 2012, vol./is. 108/(ii316-ii317), 0007-0912 (March 2012) Author(s): Weller J., Torrie J., Henderson R.

Abstract: There is limited evidence to show that anaesthetists' behaviour in the simulator reflects their workplace behaviour, or that behaviours under routine conditions predict crisis behaviours. Objectives: We compared individual anaesthetist's patterns of team interactions across three settings: the OR; a routine simulation; and a crisis simulation.

Full Text: Available in fulltext at EBSCOhost EJS Available in print at Solihull Staff Library


Title: Speaking Across the Drapes: Communication Strategies of Anesthesiologists and

Obstetricians During a Simulated Maternal Crisis.

Citation: Simulation in Healthcare 2012 May 7. [Epub ahead of print] Author(s): Minehart RD, Pian-Smith MC, Walzer TB, Gardner R, Rudolph JW, Simon R, Raemer DB.

Abstract: INTRODUCTION: Organizational behaviour and management fields have long realized the importance of teamwork and team-building skills, but only recently has health care training focused on these critical elements. Communication styles and strategies are a common focus of team training but have not yet been consistently applied to medicine. The authors sought to determine whether such communication strategies, specifically "advocacy" and "inquiry," were used de novo by medical professionals in a simulation-based teamwork and crisis resource management course. Explicit expression of a jointly managed clinical plan between providers, a strategy shown to improve patient safety, was also evaluated.

Full text: Available in Print from Harry Hollier Simulation Centre.








New Additions to the HEFT Libraries:



Developing healthcare skills through simulation
1st ed.

Author: Aldridge, M ed.

Publisher: Los Angeles :Sage Publications Ltd,
Pub Year: 2012
ISBN: 9781446201251.


Available at Heartlands and Good Hope Libraries

Reserve your copy here


If you would like to recommend any resources –books/journals/DVDs on Simulation, please email [email protected] or call x47836.












Further information:

The following sources have been searched for evidence published in the previous four weeks: Journal of Healthcare Simulation; BMJ Quality and Safety in Healthcare; NHS Institute for Innovation and Improvement; Agency for Healthcare Research and Quality; and searches on databases such as MEDLINE/EMBASE. Please contact [email protected] for any further information.


To access the full text links in this bulletin, login with your HEFT Athens ID at ‘before’ clicking on them in order to make them seamless


For more information on how to register for Athens, access the Athens Registration leaflet via HEFT Library website

Visit NHS Evidence to access your journals and databases.