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communication, (5) decision-making, and (6) program feedback. This study highlighted a CRM course that was piloted at two hospitals, in which various operating
room staff participated, including surgeons, nurses, anesthesiologists, and scrub
techs. This one-day course focused on classroom case- based studies, video training
and, ultimately, a simulation experience. Overall, from 45 workshops and 712 participants, 99% felt the program was applicable to their daily practice, and 96% found
the simulation to be more useful than the classroom- based case studies. Additionally,
participants felt an overall improvement in satisfaction with regard to goal setting
and communication within their departments. This study, similar to the previous one,
highlights that case-based courses can be an effective means for participants to learn
the importance of communication in the operating room.
A surgical team-simulation training model from Weldon etal. [10] is a type of
partial-task training simulation for team-based competency and communication.
Through the Video-Supported Simulation of Interactions in the Operating Theater
(ViSIOT), operating room teams participating in the simulation training observed
actual video footage from the operating room and identied improvements in communication techniques. In the second phase of the simulation training, the teams
implemented the strategies. This study took place in both the United States and
United Kingdom. Participants found the course to be very benecial, rating course
objectives and simulation activity higher than debrieng and course evaluations.
This study highlights that through a specic task of video assessment, the environment of team communication in the operating room can be simulated.
A full-mission simulation focusing on team-based competency and communication completely recreates a clinical experience for trainees that they can participate
in, as opposed to observe. Paige etal. [11] conducted a 2-h dual-scenario simulation
involving a full-scale computer-operated human patient simulator mannequin and
inanimate torso procedural training model. Prior to the simulation experience, there
were no didactic sessions provided. The two scenarios included a life-threatening
intra-abdominal hemorrhage from a stab wound, and local anesthetic toxicity from
a regional upper arm block. Participants included both nursing and medical students, and they demonstrated improved self-efcacy and team-based behaviors
when comparing pre- to post-session scores. Therefore, this study demonstrates that
full-mission simulation can provide trainees the opportunity to improve team-based
attitudes and behaviors, ultimately impacting the operating room culture and
patient safety.
R. M. Higgins and M. A. de Moya
Operating Room Fire Safety
Team-based competency and communication is one aspect of efforts to improve
patient safety in the operating room as it pertains to re safety. The Emergency Care
Research Institute (ECRI) identied operating room res as one of the top 10 health
technology hazards in 2019 [12]. In the operating room, a surgical re is one that
occurs on or in a patient. The components of a “re triad” that are necessary for a
re to occur include an oxidizer, an ignition source, and fuel [13]. An oxidizer
13 Simulation Technical Training toImprove Safety intheOR
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includes gases such as oxygen and nitrous oxide, which exist within the closed or
semi-closed ventilation system of the patient’s airway. An ignition source includes
products such as electrocautery devices, lasers, heated probes, coagulators, and
light cables. Finally, examples of fuel sources include drapes, gauze, alcoholcontaining skin preparation materials, and oxygen masks. Given this high- risk environment in the operating room, a focus on re safety is critically important through
institutional and national re safety protocols and educational opportunities. To prevent operating room res, staff must be aware of minimizing or avoiding an oxidized-enriched atmosphere near the operative site, and safely managing ignition and
fuel sources. One of the most effective ways to educate staff on re safety in the
operating room is through simulation.
On an institutional level, Sankaranaryanan et al. [14] developed the Virtual
Electrosurgery Skill Trainer (VEST©), which is a simulator that trains participants
in the cognitive and motor skills for safely operating electrosurgical devices, in an
attempt to minimize operating room res. The simulator is a three-dimensional display with a tissue pad that provides force feedback and simulates the physics of
electrosurgery, such as smoke and electrical spark. Through simulating the effects
of electrosurgery, surgeons can learn to avoid injury, and therefore increase patient
safety. Though VEST© is a partial-task trainer, those who have used the VEST©
simulator have found it to be visually realistic and reproducible of live tissue [15].
When the VEST© simulator was applied to a team-training module focusing on
operating room re prevention and response, 67% of participants chose the VEST©
simulator over traditional textbook or animal models [15]. This extension of the
prior partial-task trainer of the VEST© simulator itself was applied to a full-mission
simulation, where a virtual operating room environment was created including
anesthesia, electrosurgical equipment, nurses, a virtual patient, and a re extinguisher. Through a head-mounted display, participants were able to fully interact
with this virtual environment with the goal of identifying the “re triad” elements
and then successfully containing a re (Fig.13.1). Participants reported that this
Fig. 13.1 Operating room
re training simulator
interface. Used with
permission of Springer
Nature BV from OR re
virtual training simulator:
design and face validity;
Society of American
Gastrointestinal
Endoscopic Surgeons,
European Association for
Endoscopic Surgery. Vol.
31:9; copyright ©1987;
permission conveyed
through Copyright
Clearance Center, Inc
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R. M. Higgins and M. A. de Moya
virtual reality simulator was useful and effective, increasing their comfort with
managing operating room res compared to how they felt prior to the training
(Fig.13.2).
Classroom-based training is also a potential adjunct method to simulation for
managing operating room res. Kishiki etal. [16] randomized 14 groups of participants into either receiving classroom training alone prior to testing, or practice simulation followed by classroom training. The full-mission simulation environment
consisted of a patient simulator mannequin with a fog machine in an operating room
that was manipulated in an adjacent control room to produce smoke. The participants were exposed to two clinical scenarios, rst of which was a cervical lymph
node biopsy where oxygen from the nasal cannula was ignited by monopolar cautery; the second was a laparoscopic ber optic cable resting on a surgical drape.
Competency and condence scores in the simulation group were signicantly
higher than those who underwent classroom training alone.
The signicance of surgical energy and its inuence on the risk of operating room
res has been championed by the Society of American Gastrointestinal and Endoscopic
Surgeons (SAGES) through the Fundamental Use of Surgical Energy™ (FUSE) program. This program is an educational resource with a web-based multimedia curriculum and a certication examination, all focused on the competencies required to
safely use energy-based surgical devices [17]. Prior to the initial post- graduate course
piloted for this curriculum, a survey of 27 participants on surgical energy safety had a
median percent of 59% correct, compared to 90% after the course [18].
The simulation application of the FUSE curriculum was conducted by Madani
etal. [19] through a randomized, controlled trial of 56 surgical trainees. Trainees
were randomized into either an unstructured (control) or goal-directed (simulation)
hands-on session with electrosurgery devices. Control group trainees were provided
no predened tasks or objectives, in addition to electrosurgical equipment and raw
meat. Simulation group trainees had four structured, goal-directed workstations
using electrosurgical equipment and raw meat, consistent with part-task trainer
Fig. 13.2 Simulated operating room re caused by a gas enrichment area under the surgical
drape. Used with permission of Springer Nature BV from OR re virtual training simulator: design
and face validity; Society of American Gastrointestinal Endoscopic Surgeons, European
Association for Endoscopic Surgery. Vol. 31:9; copyright ©1987; permission conveyed through
Copyright Clearance Center, Inc
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simulation. The four workstations included: setup of the electrosurgical circuit,
electrosurgical tissue effects, electrosurgery-related adverse events in open surgery,
and electrosurgery-related adverse events in laparoscopic surgery. Immediate postcurriculum scores were higher in the simulation group compared to control group
(89% vs. 83%, p=0.02), as well as at 3months (77% vs. 60%, p<0.01). Through
a standardized curriculum that incorporates simulation, trainees and surgeons can
learn how to safely operate electrosurgical devices, which is critically important for
patient safety in the prevention of operating room res. For more on preventing and
managing re and smoke hazards in the OR, see Chap. 21.
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Infection Prevention andControl
Infection prevention and control is a critical part of a patient’s safety within the
hospital environment. Ten components have been identied as crucial in hospital
infection control [20]. Organization of infection control at the hospital level requires
an infection-control program, nursing staff, dedicated physicians, microbiology
support, and data management. Ward occupancy cannot exceed the capacity in
regard to rooms or workload by the healthcare provider staff, as methicillin-resistant
Staphylococcus aureus has been associated with bed occupancy and low nurse staffing. Materials and equipment must be compliant, such as hand-washing dispensers,
isolation precautions, and dedicated central venous catheter kits. The use of guidelines, education, and training are another signicant component of infection control.
Optimizing these components can be challenging, but simulation-based training can
aid in emphasizing the signicance and importance of infection control.
Breckwoldt etal. [21] provided a 2-h teaching module in a simulated operating
room setting for students, consistent with a case study and role play type of simulation. In this module, students were provided four workstations: operating room
entry, surgical hand disinfection, dressing for surgery with disinfection of the surgical eld and applying surgical drapes, and a debrieng. The debrieng focused on
the safety culture in the operating room. Overall, trainees rated the teaching module
with high overall satisfaction and teaching quality. Therefore, it is important to provide training in infection control and prevention regardless of training level and has
been effective through simulation-based teaching modules.
Operating Room Crisis Resource Management
Surgical crises in the operating room are rare, but when they occur, require immediate and efcient intervention to minimize harm to the patient. Emergency manuals,
or crisis checklists, have been found to be helpful, given that stressful situations can
signicantly impair individuals’ ability to think clearly and efciently [22]. Four
vital elements for implementing emergency manuals include create, familiarize,
use, and integrate. These manuals must be created appropriately for the context,
familiar to those who will use them, accessible and effectively used, and supported
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by the institution’s safety and quality culture [23]. However, the mere presence of
these manuals does not guarantee their utilization in crisis situations. Therefore, the
role of simulation and training becomes important to train staff about the utility of
these emergency manuals.
Through a full-mission simulation, 126 participants were involved in a 50-min
simulation-based training session on how to use emergency manuals, integration
into teamwork and communication, and simulated scenarios of critical events [24].
The critical events that were simulated included malignant hyperthermia and massive hemorrhage. A cardiopulmonary mannequin with externally controlled vitals
was used for the simulation. By fully immersing the participants in the operating
room, they were able to simulate a realistic operating room environment. A total of
nine training sessions were conducted over 5months. After the simulation, participants reported signicantly increased awareness of and familiarity with the emergency manual, willingness to use it for educational review, and suggest its use in
crisis situations although no data has yet been provided for its use in practice.
Another institutional study used an operating room comprehensive unit-based
safety program (CUSP) team to evaluate instituting surgical crisis checklists, specically in regard to cardiac arrest [25]. The purpose of the checklists was to provide
appropriate steps, medication dosages and treatments, and role assignments during
emergencies. Initially, small-scale case study and role play simulations were conducted outside the operating room environment, where team members assumed the
roles of the surgical team and practiced responding to a cardiac arrest using a checklist. This smaller scale simulation was then expanded to a full-mission simulation with
a mannequin in the operating room, where there was also a debrillator and emergency cart present. During and after the simulation, 80% of participants were comfortable with caring for a cardiac arrest patient. Therefore, simulation training provides a
strong foundation for operating room staff in the management of a surgical crisis.
The importance of simulation in surgical crises has also been identied in a multiinstitutional study. Arriaga etal. [26] conducted a study across three institutions that
participated in surgical-crisis scenarios in an operating room, consistent with fullmission simulation. A total of 17 operating room teams participated in 106 surgical
crisis scenarios. Of those scenarios, half were randomized to be managed with crisis
checklists, and the other half only from memory. When checklists were available, only
6% of steps were missed, compared to 23% when the crisis was managed from memory alone (p<0.001). Overall performance was improved when the crisis checklists
were used. Of the participants, 97% stated they would want the checklist used if they
were undergoing an operation. This simulation demonstrated that the use of checklists
provides an opportunity to optimize patient care in surgical crisis scenarios.
R. M. Higgins and M. A. de Moya
Technical Skills Training
Simulation that provides the opportunity for surgeons and trainees to practice technical skills undoubtedly improves condence and competence [27–29]. The correlation of competence gained from simulators and improvement in patient safety and
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outcomes has not yet been identied in the literature. However, it is certainly a
reasonable assumption that improved training paradigms with simulators can lead
to earlier competence in training, and therefore improved patient safety in the operating room. Specically, simulators with assessment components that provide trainees and surgeons with feedback about their performance and goals toward achieving
competence are important in achieving this goal.
Partial-task trainers, focusing on endoscopic, laparoscopic, and robotic skills, have
been the most commonly used simulators for technical skill training in the operating
room. Laparoscopic skill simulation trainers include both virtual reality and box trainers [30]. Virtual reality trainers allow for repeated practice without the cost or risk of
practicing on an animal, cadaver, or human patient [31]. These established virtual
reality systems include procedure simulation for bronchoscopy, colonoscopy, gastroscopy, and laparoscopy. These virtual reality platforms have demonstrated a signicant
transfer of skills in performance of a laparoscopic cholecystectomy by residents in
regard to operative time, injury rate, and progress through the operation [32]. Through
technical skill competence, undoubtedly patient safety is affected as a result.
The fundamentals of laparoscopic surgery (FLS) uses box trainers for simulation. Through these box trainers, residents are trained in ve tasks: (1) peg transfer,
(2) precision cutting, (3) loop ligation, and suturing with both (4) extracorporeal and
(5) intracorporeal tying [33]. The American Board of Surgery now requires that all
residents pass the FLS assessment examination to become board eligible. This
assessment includes web-based didactic, hands-on skills training, and an examination. This is a similar requirement for the fundamentals of endoscopic surgery
(FES). However, unlike using a box trainer as in FLS, residents use a virtual reality
simulator in FES to mimic skills needed for colonoscopy and gastroscopy through
various training modules.
Technical skill simulation for robotic surgery involves a partial-task trainer using
the daVinci skills simulator (dVSS). This is a simulator backpack that sits on the back
of the robotic surgeon console. Exercises on the simulator include camera manipulation, energy transmission, dexterity, range of motion, fourth arm control, and needle
driving. Scores on each of these exercises are tracked, and trainees are provided feedback and assessment reports on their performance after completing each task. Robotic
procedural simulation is being introduced in certain specialties but has yet to become
prevalent in general surgery [34]. A standardized robotic skills assessment has yet to
be established, unlike in laparoscopic and endoscopic surgery [35].
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Conclusion
Simulation in the operating room is critically important to provide an opportunity
for learning and training in a well-controlled environment. All types of simulation
have their role and can be applied in various training paradigms. Through simulation training in team-based competency, re safety, infection prevention and control, crisis management, and technical skills training, all providers and staff within
the operating room can work together to maximize patient safety.
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R. M. Higgins and M. A. de Moya
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Simulation toImprove Safety intheOR
JamieL.Sparling andJeffreyB.Cooper
Introduction
The Society for Simulation in Healthcare (SSH) denes simulation as, “the imitation or representation of one act or system by another.” [1] In healthcare, simulation
is generally thought of as an educational and training tool, especially in surgical
disciplines. Importantly, however, simulation is also highly leveraged as a tool to
improve patient safety, as well as for research and performance assessment. In the
current healthcare system, where basic science education and individual skills are
prioritized, simulation offers an opportunity to enhance the performance of clinical
teams working as a cohesive unit [2].
In this chapter, we will describe the historical context of simulation use in healthcare, detail the role for simulation in patient safety, compare medical simulation
with other industries, review various forms of simulation, explore its specic use in
the perioperative context, and discuss implementation.
14
J. L. Sparling (*)
Department of Anesthesia, Critical Care, & Pain Medicine, Massachusetts General Hospital,
Boston, MA, USA
Department of Anesthesia, Harvard Medical School, Boston, MA, USA
e-mail: jlsparling@mgh.harvard.edu
J. B. Cooper
Department of Anesthesia, Critical Care, & Pain Medicine, Massachusetts General Hospital,
Boston, MA, USA
Department of Anesthesia, Harvard Medical School, Boston, MA, USA
Center for Medical Simulation, Boston, MA, USA
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_14
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J. L. Sparling and J. B. Cooper
History ofSimulation inMedicine
Simulation is widely used in high-risk elds including aviation, nuclear power, and
chemical plants, where it is often required by regulations. For example, the Federal
Aviation Administration (FAA) established the National Simulator Program (NSP) to
administer its safety simulations and has expanded since the 1970s to now include
certication of ight simulation training devices (FSTDs) [3]. Similarly, the
U.S.Nuclear Regulatory Commission (NRC) requires that nuclear power plant operators complete ongoing simulation, and it certies simulation facilities and ensures their
continued delity [4]. It is only more recently, and in part from the lessons of those
other industries, that simulation is used for healthcare education and patient safety.
This may be, in part, due to the overall under-regulation of healthcare, and the sense of
autonomy among healthcare practitioners. Moreover, as compared with the aforementioned industries, safety events in healthcare tend to cause harm to one patient at a time
rather than mass casualties. And, because many errors in healthcare cannot be easily
separated from the underlying disease process “taking its course,” actions on the part of
healthcare teams that may be remedied are more easily overlooked.
Although widespread use of simulation in healthcare is relatively recent, there is a
history of simulation dating back more than a hundred years, with many uses in the
nineteenth century. For example, as far back as 1740, simulators or “obstetric machines”
were used to teach obstetric skills. The rst known doctoral thesis on simulation was
published in 1797 titled, “A short account of likenesses or devices for practicing obstetric skills also called phantoms.” [5] Modern healthcare simulation, however, has its
roots in the 1960s [6, 7]. There was a large leap forward, driven by patient safety, starting in the late 1980s [6, 8]. Anesthesiology was among the rst specialties to use critical-incident analysis to examine patient safety events [9]. The concern for safety led to
the development of many interventions, including simulation, to avoid preventable
harm. Further, medical education began to incorporate computer-based simulation during the 1970s as computers became more widespread. In a 1984 report, the Association
of American Medical Colleges (AAMC) urged medical schools to “require students to
be active, independent learners and problem solvers” and to “lead in the application of
information science and computer technology and promote their effective use.” [10,
11] This was an indirect encouragement for simulation.
As a specialty, anesthesiologists began to incorporate simulation as a component
of the patient safety movement. The Anesthesia Patient Safety Foundation (ASPF)
was formed in 1985 under the leadership of Dr. Ellison C. (Jeep) Pierce, Jr., and early
on reinforced the concept of simulation as a tool to improve the delivery of safe anesthetic care [12]. The APSF was the rst multidisciplinary organization to include not
only anesthesia practitioners, but also equipment and drug manufacturers and other
professionals in a broad collaboration to improve perioperative safety. At the time of
its inception, anesthesia was thought to contribute to a mortality rate of 1–2/10,000
anesthetics, reecting the time period from the 1950s–1970s. Additionally, media
coverage in the early 1980s reported harshly on anesthesia events that contributed to
patient harm. By the late 1980s, the APSF provided grant funding to develop highdelity patient simulators for use in education, teamwork, and critical event training,
and human factors research. Since then, medical simulation has expanded to virtually
all medical specialties and to all allied health professions.
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