E. W. M. Samuel1, E. Broughton1, A. Ross1, L. Chigaru1, S. Jinks2, P. Nambyiah2

1Great Ormond Street Hospital NHS Trust, Cambridge, UK

2Great Ormond Street Hospital NHS Trust, London, UK

Non-technical skills, including failure in teamwork and lack of confidence, have been identified as important culprits in the failure to provide appropriate, safe care to patients. Traditionally, simulation in healthcare has been used to educate participants and improve their practice without posing potential harm to patients. Recently, its application has extended into stress testing systems to identify areas of latent safety threats and inefficiencies. (1–3)

We present an example of using simulation to improve systems and the safety of patient care at the GOSH Clinical Simulation Centre (CSC). This started during the COVID-19 pandemic and continued afterwards.


We conducted 14 simulation scenarios over 18 months, at the GOSH CSC. During the debriefs, we focused on learning points, observations, and actions to improve teams’ practice. The assessors reported the points discussed and categorised them into communication-related, environment-related, and equipment-related sections. In each section, they recorded observations, actions, and escalation plans to implement changes. We analysed the data and extrapolated common themes to all scenarios, and measures specific to each situation.


As per Figure 1.1, eight scenarios were analysed. The COVID-related scenarios focused on the safety of patients and staff, and transferring COVID-positive patients for interventions in clean areas. The non-COVID-related scenarios addressed emergencies, including fire evacuation in new buildings, managing malignant hyperthermia in remote theatres, neonatal transfer from Neonatal ICU for interventions in remote areas, and testing new theatres for safety.

Factors identified for improvement in the COVID-related scenarios included the risk of contaminating clean areas and staff, unclear roles of clean and contaminated staff members, support required for patients’ transport, and proper communication between clean and contaminated staff members. Suggested actions were then escalated to responsible team members in the relevant areas, and included in the WHO checklists, SOPs and debriefs.

Factors identified for improvement in the non-COVID-related scenarios included leadership, safe handling of patients during emergencies, role allocations, and place orientation of some staff members. The actions escalated included creating tools for better team communication, using visual aids for space orientation in cases of emergencies, and stating clearly in the guidelines the places of emergency drugs and equipment. This was escalated via relevant team leaders and using checklists and SOPs.

We repeated the scenario of malignant hyperthermia after implementing the actions identified previously, and it showed improvement in efficiency and time management of the emergency.

Discussion and conclusion:


Simulation may be most beneficial when focused at improving systems and processes, not just healthcare workers’ skills & behaviour. Analysing scenario outcomes, having clear objective measures to achieve, making suggested changes, and then repeating the scenarios proved to be a reliable and reproducible way to measure the effectiveness of simulation in improving practice.


  1. Freytag J, Stroben F, Hautz WE, Penders D, Kämmer JE. Effects of using a cognitive aid on content and feasibility of debriefings of simulated emergencies. GMS J Med Educ. 2021;38(5):Doc95.
  2. Shear TD, Greenberg SB, Tokarczyk A. Does training with human patient simulation translate to improved patient safety and outcome? Curr Opin Anaesthesiol. 2013 Apr;26(2):159–63.
  3. Colman N, Doughty C, Arnold J, Stone K, Reid J, Dalpiaz A, et al. Simulation-based clinical systems testing for healthcare spaces: from intake through implementation. Adv Simul. 2019 Aug 2;4(1):19.
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