Rol De La Simulacion En Anestesia

Advances in Anesthesia 26 (2008) 213–224

ADVANCES IN ANESTHESIA The Role of Simulation in Anesthesia Robin L. Wootten, MBA, RNa,b,*, Gregory Sorensen, MDc, Tasha Burwinkle, PhDd a

Russell D. and Mary B. Shelden Clinical Simulation Center, Clinical Support and Education Building, Five Hospital Drive, Columbia, MO 65212, USA b The Standardized Patient Program, The University of Missouri School of Medicine, Clinical Support and Education Building, Five Hospital Drive, Columbia, MO 65212, USA c Pediatric Specialty Care, Swedish Medical Center, 747 Broadway, Nordstrom Tower, Suite 650, Seattle, WA 98122, USA d Gossman Center for Pediatric and Perinatal Simulation, Swedish Medical Center, 747 Broadway, Nordstrom Tower, Suite 650, Seattle, WA 98122, USA

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or decades, simulation has been used as a training tool to evaluate the performance of airline pilots, astronauts, nuclear engineers, and military personnel. Simulation in medicine was first introduced in the 1960s, although increased attention to medical simulation did not emerge until the 1980s when advances in technology allowed for increased feasibility in producing high-fidelity simulators [1]. In 2000, the Institute of Medicine (IOM) report ‘‘To Err is Human’’ highlighted the importance of patient safety when it estimated that one million people are injured annually by errors in treatment at United States hospitals, with as many as 98,000 deaths arising from those errors [2]. As a result, the IOM recommended that health care organizations establish team training programs for personnel in critical care areas using simulation whenever possible [2]. Training multidisciplinary teams using simulation allows for communication, accountability, and the development and maintenance of effective teamwork [3,4]. In fact, team training has become increasingly important. It will most likely become a requirement for hospital credentialing; the Joint Commission on Accreditation and Healthcare Organizations (JCAHO) has issued a sentinel alert that organizations conduct team training to teach staff to work together and communicate more effectively [5]. In anesthesiology, simulation has been used for many years in the preparation of practitioners. In many ways, anesthesiologists around the world are leading the way in innovative ideas centered on the addition of simulation to medical education at all levels. This article highlights literature showing the *Corresponding author. Clinical Support and Education Building, Five Hospital Drive, Columbia, MO 65212, USA. E-mail address: [email protected] (R.L. Wootten). 0737-6146/08/$ – see front matter doi:10.1016/j.aan.2008.07.004

ª 2008 Elsevier Inc. All rights reserved.

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evolution of simulation over the past decade. The review is not all-inclusive of the many innovative ideas present in today’s medical schools or academic health centers but is a brief overview of what is emerging as the next generation of medical education. USES FOR SIMULATION In general, medical simulation has been used for the following: to promote rehearsal of clinical and nonclinical (ie, communication) skills; to practice complex medical procedures and critical events; for team and individual training; to experiment with novel interventions; to introduce new equipment/technology; to assess performance; and ongoing training [1]. In anesthesia, specifically, simulation can be used to provide training in technical skills (ie, dosing, airway management), behavioral skills (ie, communication, teamwork, leadership), cognitive skills (decision-making), crisis management (ie, Anesthesia Crisis Resource Management [ACRM]), and competency (ie, credentialing, clinical assessment), as well as training in new technologies, equipment, or pharmaceuticals. For graduate trainees, the Accreditation Council for Graduate Medical Education (ACGME) has outlined six domains of clinical competence, including: (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. Simulation can be used to evaluate performance in each of these domains. There are a number of reasons why simulation is used in health care environments. First and foremost, use of simulation provides no risk to patients; errors may be elicited and corrected without consequence. Simulation also allows for the presentation of a wide variety of scenarios (including less frequent but still critical events), and simulation provides flexible, job-specific training and hierarchical learning that can be tailored to a participant’s skill level and/or learning style. Simulation can also be used at any time, in an on-demand fashion. Thus, training does not have to be delayed due to ‘‘real patient’’ variables. Unlike patients, simulators do not become embarrassed or stressed, have predictable behavior, and are available at any time to fit curriculum needs. In addition, they can: be programmed to simulate selected findings, conditions, situations and complications; allow standardized experience for all trainees; be used repeatedly with fidelity and reproducibility; and be used to train both for procedures and difficult management situations [6]. With regard to assessment, the use of an anesthesia simulator offers a number of advantages over traditional assessment methods. First of all, scenarios can be standardized so that multiple teams of learners can be trained in the same way, which is especially helpful for assessment and credentialing. By standardizing the scenarios, scripting the responses to the problems, and having the observers view the same events, differences attributed to the ‘‘patient,’’ the candidates, or the conduct of the examination are eliminated [7]. Secondly, simulation allows for multidisciplinary learning: medical students, residents,

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fellows, physicians, nurses, phlebotomists or others can all be trained using medical simulators. With the increased focus on patient safety, simulation training has been well documented in the literature. McGaghie and colleagues [8] conducted a systematic review of 670 peer-reviewed journal articles related to high-fidelity medical simulation in a range of disciplines, including anesthesia. The authors conclude that there is ‘‘clear evidence from these research studies that repetitive practice involving medical simulation is associated with improved learner outcomes.’’ Furthermore, they identified a dose-response relationship such that more practice yielded better results for all levels of learners (including students, residents, and attending physicians). Simulation has been found to be effective in reducing surgical errors [4], reducing perinatal asphyxia and neonatal hypoxic ischemic encephalopathy in obstetrics [9], and reducing errors in labor and delivery [10]. In anesthesia, simulators have been shown to assist in identifying and documenting common errors and critical incidents [11,12]. In the DeAnda study [11], 66% of incidents were due to human error, of which 27% were considered critical. Schwid & O’Donnell [12] found that the most common errors in anesthesia were due to: improper monitor usage; improper airway and ventilator management; and improper drug administration. Studies in anesthesia with residents and practicing anesthesiologists indicate that simulators have been evaluated as realistic and that training on simulators improves acquisition and retention of knowledge above and beyond traditional lectures [13]. Assessment of skill performance has also been conducted in anesthesia simulation; studies indicate that trainees who participate in simulation respond to and manage critical incidents better than trainees who do not participate in simulation [14,15]. Participants of varying skill levels (eg, residents, nurses, anesthesiologists) who have assessed their own performance likewise felt that simulator-based scenarios helped them to manage difficult airway situations in their daily clinical practice more so than lectures and skill stations [16]. One study concluded that the course effectively improved self-assessed airway management competence, confidence of skills, and management of department resources. A recent review of centers around the world that use simulation in anesthesia training found that postgraduate training and education focused on crisis management and rare events, with less emphasis on areas such as advanced cardiac life support (ACLS) and technical skills [17]. Alternatively, undergraduate anesthesia training focused primarily on physiology/pharmacology, monitoring, airway management, and technical skills. The major benefits of simulation reported in the review, in order of importance, included: experiential learning; management of critical or rare events; educational tool; patient safety; and reproducibility. Conversely, the most commonly identified challenges to the use of simulation included: lack of financial resources; lack of human resources; technical problems; lack of time; and lack of validation of education/evaluation model [17].

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ERRORS IN SIMULATION Because of the controlled environment and the audio/visual capture of training in many simulation centers, certain errors are seen on a recurring basis. These errors, outlined by Lighthall [18], are described in Table 1. Because these errors are complex and multi-dimensional, it is not feasible to think that a single session with individual learners will correct these recurrent errors. However, repeated multidisciplinary team training such as ACRM with random teams, coupled with debriefing, can help learners reflect on their own performance and work to change their behavior in a crisis. Because the environment is safe and nonthreatening, competence can be built individually and as a team, regardless of learner level of knowledge or experience. EFFECTIVE LEARNING IN SIMULATION According to Issenberg and colleagues [19], ‘‘the Best Evidence Medical Education (BEME) collaboration involves an international group of individuals, universities and organizations (eg, Association for Medical Education in Europe [AMEE] and Association for American Medical Colleges [AAMC]), committed to moving the medical profession from opinion-based education to evidence-based education.’’ In a comprehensive review covering 34 years of existing evidence regarding medical simulation, Issenberg and colleagues summarized ‘‘that high-fidelity medical simulations facilitate learning under the right conditions.’’ The following factors, condensed from the BEME article, provide the basis for effective learning through simulation and they are a good foundation when thinking of adding simulation to existing medical school or postgraduate curriculum (Table 2). Issenberg and colleagues concluded that: ‘‘high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings’’ [19]. Table 1 Errors in simulation Technical errors Compliance errors

Judgment errors Fixation errors

Communication errors

Learners choose improper medications or dosages or misinterpret cardiac rhythms and treat inappropriately Failure to perform advanced cardiac life support (ACLS) correctly, failure to use personal protective equipment (PPE) or universal precautions, failure to use sterile technique when appropriate, failure to use CO2 detector after intubation Failure to respond to drastically abnormal vital signs and changes in patient status. Becoming absorbed with diagnosing the patient or on a specific task; not responding to alarms or taking primary steps to stabilize patient Requests of team leader not heard or followed up on

Reproduced from Lighthall GK. The IMPES course: Toward better outcomes through simulation-based multidisciplinary team training. In: Dunn WF, editor. Simulators in Critical Care and Beyond. Des Plaines, IL: Society of Critical Care Medicine; 2004:54–60. Copyright ª Society of Critical Care Medicine. Reproduced by permission of the Publisher.

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Table 2 Conditions of high-fidelity simulation that facilitate learning Providing feedback

Repetitive practice

Curriculum integration

Varying levels of complexity

Multiple learning strategies

Capture clinical variation

Controlled environment

Individualized learning

Defined educational objectives

Fiction contract

Post-simulation feedback has been found to be the most important factor contributing to effective learning and maintenance of acquired skills. Engaging in focused, repetitive practice in a controlled environment enhances skill acquisition and time performance Simulation should not be viewed as a unique experience, but rather as a part of a normal training regimen, equal in importance to patient care experiences. Novice learners should be given objective criteria to master, building up to higher levels of expertise, including team leadership and cognitive complexity scenarios. Learners will have a better experience if they encounter individual, small group, and large group training, in addition to independent, objective-based learning without an instructor. Scenarios are most effective when a broad variety of cases (including common, rare, and crisis events) are presented. Conducting simulation in an environment that can be controlled allows the learner to ask questions, make mistakes, and correct patient care errors without adverse outcomes. Simulation is most effective when training is specifically focused to meet an individual’s unique needs, giving the learners confidence in their abilities. Creating educational objectives before scenario creation allows the simulation team to determine the best simulation method to meet the objectives and to determine the appropriate outcomes to be measured. Asking the learner to engage in a scenario as an active participant who views the simulator as a ‘‘real’’ patient facilitates the validity of the simulation experience.

From Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005;27(1):10–28.

USE OF COGNITIVE AIDS IN LEARNING More and more, simulation is being used to create a controlled environment that exposes individuals and teams to highly critical, even rare, incidents. During these incidents, learners are asked to apply knowledge, skill, and even leadership abilities to achieve the best outcome for the patient. For example, ‘‘the Department of Anesthesiology at the University of Kentucky has developed a program using human patient simulation that exposes anesthesia residents, before their

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rotation in cardiac anesthesia, to a simulated patient undergoing cardiopulmonary bypass.’’ The purpose of this simulation is to ‘‘introduce principles of cardiac anesthesia and cardiopulmonary bypass management and allow exposure to complications and management of patients undergoing cardiopulmonary bypass’’ [20]. Through checklists, structured learning, and perseverance, residents gain the knowledge and confidence to attain this highly critical skill set. The use of cognitive aids such as detailed checklists have been shown to improve outcomes in highly stressful, critical events. In a malignant hyperthermia (MH) study completed by the Patient Simulation Center of Innovation at Veterans Affairs (VA) Palo Alto Health Care System and the Department of Anesthesia, Stanford University School of Medicine, Harrison and colleagues [21] found that there is ‘‘a strong correlation between the use of a cognitive aid and the correct treatment of MH.’’ Their findings also show better performance and fewer errors by those teams of practitioners who used cognitive aids. The conclusion of their study states that ‘‘because it is impossible to determine prospectively if a team will perform well in a crisis, it might be prudent to encourage all teams to refer to and use a cognitive aid in unfamiliar or life-critical situations to maximize the likelihood of successful resolution.’’ In the same study, residents were interviewed to assess what barriers they face in their choice of whether to use a cognitive aid in critical situations. They found that ‘‘many felt that using a cognitive aid would tend to show weakness and give the impression that they did not know what to do in a crisis.’’ In ‘‘. . .other highrisk professions, such as aviation or spaceflight, checklists and other cognitive aids are used as part of standard operating procedures. Negative stereotypes about the use of cognitive aids in health care should be confronted’’ [21].

ANESTHESIA NONTECHNICAL SKILLS TRAINING While traditional anesthesia training has focused on acquiring and mastering technical skills, recent studies have found that nontechnical skills (eg, decision making, communication), which are generally not directly taught, are major determinants of successful anesthesia crisis management [22]. One method of assessing nontechnical skills is being developed and evaluated in a collaborative project between the University of Aberdeen Industrial Psychology Research Center and the Scottish Clinical Simulation Center [23]. It is called the Anesthetists’ nontechnical skills (ANTS) system. The ANTS system includes four basic skill categories: 1) Task management, including planning and preparing, prioritizing, providing and maintaining standards, and identifying and using resources; 2) Team work,including coordinating with team members, exchanging information, being assertive, assessing capabilities, and supporting others; 3) Situation awareness,including information gathering, recognizing and understanding, and anticipating problems; and 4) Decision-making,including identifying and selecting options, balancing risks, and reevaluating.

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CRISIS RESOURCE MANAGEMENT Gallagher and Issenberg [24] describe the basis for simulator-based behavioral training in anesthesia. They state ‘‘most of us are good at clinical things, as we do them every day. We replace blood, treat bronchospasm, intubate. But we rarely practice the behavioral things (such as role clarity, communication, and global assessment) so critical in an emergency.’’ This philosophy was reflected in the development of ACRM training designed by physician educators at VA Palo Alto and Stanford [25] and based in part on simulation in other disciplines such as aviation, where crew resource management (CRM) has been used extensively to train for crisis situations during flight. The ACRM group sought to determine the gaps in anesthesia training. It found three major areas of inadequacy:   

Dynamic decision-making Allocation of attention Team management behaviors

To target these gaps, the goal of the resultant ACRM training is to provide comprehensive teaching and practice in the integrated use of technical, cognitive, and behavioral skills in managing crises by focusing on several key points, which include: anticipating and planning; mobilizing all available resources; communicating effectively; using cognitive aids; reevaluating; and using teamwork [25]. The ACRM system can assess technical performance, such as placement of instruments or administration of medications, as well as behavioral performance (ie, the appropriate use of sound crisis management behaviors including leadership, communication, and distribution of workload to other members of the team) [26]. Furthermore, ACRM training requires that the anesthesia learners become familiar with: 

  

Specific technical skills applicable to situations relevant to their domain, in the context of a wide variety of types of clinical situations (eg, cardiac, orthopedic, or general surgery, labor and delivery, intensive care); Generic skills of dynamic decision-making, resource management, leadership and teamwork applicable to any challenging clinical situation; Working effectively with a spectrum of personalities and behaviors of other crew or team members; and Organized learning after adverse clinical occurrences through individual and group debriefing and by analyzing reports of adverse events.

A survey of ACRM training indicated that participants perceived a long-term change in communication, leadership, and collaboration with colleagues, as well as improved problem-solving [27]. As a result of the success of the program, a number of health care institutions have adopted ACRM training in an effort to promote patient safety and address gaps in team training. DEBRIEFING The debriefing process following a scenario is a critical component of medical simulation because it allows trainees to reflect on their performance as well as

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receive instructor’s feedback [28]. Debriefing has been shown to result in significant improvements in subsequent scenarios compared with participants who do not receive debriefing [28]. Because feedback has been noted as the most important factor in the acquisition and maintenance of skill [19], it is highly important for the practitioner to consider the way in which that feedback will be provided. In a review of the current literature on feedback methods, Fanning and Gaba [29] provide the novice with basic information about debriefing. Noting that learners in medical simulation environments are adult professionals, Fanning and Gaba [29] state they ‘‘must make sense of the events experienced in terms of their own world. The combination of actively experiencing something, particularly if it is accompanied by intense emotions, may result in long-lasting learning.’’ Reflection on this learning event enhances the experience. However, ‘‘not everyone is naturally capable of analyzing, making sense, and assimilating learning experiences on their own, particularly those included in highly dynamic team-based activities. The attempt to bridge this natural gap between experiencing an event and making sense of it led to the evolution of the concept of . . . debriefing. As such, debriefing represents facilitated or guided reflection in the cycle of experiential learning.’’ Although there are many different ways to facilitate a debriefing session, Fanning and Gaba [29] list the seven common structural elements involved in the debriefing process: 1. 2. 3. 4. 5. 6. 7.

Content expert to conduct debriefing session Participants to debrief An experience (simulation scenario) The impact of the experience (simulation scenario) Recollection Report Time

In addition, they give practical tips for levels of facilitator involvement: 





High-level debriefing is used when the group needs very limited guidance from the facilitator. The learners engage in discussion readily and only need limited input to meet objectives. Intermediate-level debriefing requires an increased level of facilitator involvement. The learners may need assistance in analyzing the deep meanings of behaviors or attitudes. Facilitators generally ask multiple questions and involve all group members in active discussion to meet objectives. Low-level debriefing requires intensive facilitator involvement. These learners show little initiative to engage in discussion about the experience and respond only when asked specific questions. The facilitator is largely in control of the discussion, and may restate and reword questions many times to meet objectives.

Fanning and Gaba conclude that it is important to allow the group to debrief at the highest level they are capable of. Briefing the learners before the scenario will help to clarify objectives and expectations of the learning experience.

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QUALITY IMPROVEMENT THROUGH PATIENT SAFETY Can simulation play a significant role in patient safety? From an anesthesiology perspective, safety has been a strong consideration for many years. According to Gaba [30], ‘‘the physiology of patients during anesthesia changes dynamically, so that a rapidly varying and fully interactive simulation is needed to fully capture the challenging aspects of care. . .anesthesiologists are, by nature, interested in the need to manage unusual but lethal events. Anesthesiology has taken a special interest in patient safety, human performance, and human factors issues at a national level. In part, this is because anesthesia is not itself therapeutic. Since anesthesia offers only risks, not benefits, a focus on avoiding risk is understandable.’’ This emphasis on safety has become even more important to the rest of the health care environment, largely due to the IOM report ‘‘To Err Is Human: Building a Safer Health System’’ [2]. Why do accidents occur in health care? Cooper [31] states, ‘‘accidents are almost always complex events, easy to see in hindsight but not so easy to see forming at the time that they happen. . .the underlying causes of accidents are the deficiencies and weaknesses of the systems for delivering care. While health care workers of all kinds (eg, physicians, nurses, therapists, technicians, physician assistants) do make mistakes, factors associated with the design of the system almost always either encourage error and/or do not encourage discovery and recovery from error. Separating preventable actions or inactions that lead to harm is difficult when patient-related issues, especially for sicker patients, often contribute to an adverse outcome.’’ Furthermore, Cooper [31] states that when considering patient safety, ‘‘simulation has applicability in many ways. Perhaps foremost is that the mere use of simulation and providing training for personnel demonstrate commitment to a safety culture. Several specific applications of simulation fit:        

Routine training for emergencies Training for teamwork Establishing an environment for discussing error without punishment Testing new procedures for safety Evaluating competence Usability testing of devices Investigating human performance Providing skills training for novices outside of the production environment’’

Cooper concludes that: ‘‘patient safety is not the only reason to use simulation, but because patient safety is so fundamentally important to health care, it is an important lever for adoption of a concept that has the potential to radically alter the ways that clinicians are trained and patients are cared for. It’s the right thing to do.’’ DEVELOPING SCENARIOS AND MAKING TIME FOR SIMULATION With heavy clinical demands on anesthesia personnel, it seems near impossible to add another thing to the busy day. Considering the demands for monitored

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80-hour work week, even academic medical centers struggle with effective ways of adding simulation to the curriculum. Because resources are limited in most facilities, the commitment needed for simulation to be effective can be considered too costly by decision-makers. Additionally, it is hard to prove the actual benefit of simulation in monetary values. Although some institutions have committed to limited amounts of simulation, it is near impossible to see true results without a full commitment to frequent, consistent simulation exercises for all staff. The most effective simulation experience will include buy-in from hospital administration, nursing leaders, physicians, staff, and other multi-disciplinary teams who may be asked to participate in scenarios. Precise planning is important to ensure that simulation is efficient and effective. Table 3 shows a list of steps to consider when developing meaningful simulation encounters. Table 3 Steps to consider when developing simulation scenarios 1. 2. 3. 4.

Define learners: Individuals or groups, single discipline or multi-discipline Explore experience level of individual or team: Novice, expert, or mixed Consider your environment: Prehospital, OR, ICU, simulation center, or other Define objectives: Write out clear, concise goals for your simulation and how you will measure outcomes. 5. Recognize time factors: To be efficient, create scenarios that can be completed within one hour (ie, 15-min briefing, 20-min scenario, 15-min debriefing, and 10-min evaluation/ return to work station). Encourage learners to arrive on time and be prepared to start and end promptly. 6. Create cases: Develop an outline for the case from the learner’s perspective (eg, what do they need to know to care for this patient effectively and what will happen throughout the case). 7. Enlist simulation specialist: Enlist the assistance of a simulation specialist, if you have one in your facility. There may be a case already written that can be altered to meet your needs. Or, the specialist may be able to give you additional information about the most efficient kind of simulation to meet your objectives. 8. Consider the human factor: Because mannequins do have limitations, consider adding a ‘‘family member’’ or standardized patient to increase ‘‘realness’’ and the learning potential for the participant. 9. Monitor the scenario: Decide how you will monitor skills and behavior of the learners. It is often helpful to have a checklist that can be easily followed by observers during the scenario. 10. Specify video/audio needs: If your scenario will be recorded, prepare to obtain consent from your learners. If possible, bookmark areas of the recording to return to after the scenario. 11. Plan the briefing/debriefing sessions: Before the scenario, brief learners with written objectives, answer all questions, and allow new learners to become familiar with the mannequin and environment. After the scenario, conduct debriefing based on the learning objectives, ask open-ended questions, and engage learners to lead discussion. Help facilitate when needed. 12. Evaluate: Ask your learners to evaluate the session and how it could be better for them. Consider if you will retest your learners after the encounter. 13. Share your information: Decide what you will do with the information gained from the simulation encounter. If working with teams, plan to update multidisciplinary managers with results and further simulation suggestions.

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SUMMARY Medical simulation in anesthesia education is a growing enterprise that facilitates learning for individuals and multidisciplinary teams in hospital and school environments. Training has a wide range of applications, from basic to advanced technical skills acquisition, to interpersonal factors such as communication and teamwork. This training can be provided through the use of high-fidelity simulation as well as other methods such as standardized patient scenarios and task trainers. Much of the valuable research in simulation is quantitative, with reports of the benefits of simulation in multiple environments. Unfortunately, systematic research demonstrating the efficacy of simulation-based education using controlled clinical trials with adequate power is lacking, as many extant studies employ small sample sizes with weak methodology and limited generalizability [1]. A number of authors [1,19], however, have indicated a need for robust studies in medical simulation, so that the benefits of medical simulation can be demonstrated empirically. In addition to the lack of robust research, there are other limitations to simulation. Despite advances in simulator development, even high-fidelity simulators are imperfect. Although they have come a long way in replicating human likeness, there remains a degree of low face-validity, or realism, in simulation. Some trainees, for example, know that the simulator is not a ‘‘real patient,’’ and so may behave differently than they might in ‘‘real’’ situations. Future developments in simulator technology will likely help to improve the fidelity of training scenarios, which will in turn, improve the assessment of trainee performance. In the meantime, simulation-based medical education is best employed to prepare learners for real patient contact, as it allows them to practice and acquire patient care skills in a controlled, safe, and forgiving environment [19]. After all, in the words of David Gaba [32], a pioneering force in the development of medical simulation: ‘‘no industry in which human lives depend on skilled performance has waited for unequivocal proof of the benefits of simulation before embracing it.’’ References [1] Bradley P. The history of simulation in medical education and possible future directions. Med Educ 2006;40:254–62. [2] Kohn L, Corrigan J, Donaldson M, editors. To err is human: building a safer health system. Institute of Medicine (IOM). Washington, DC: National Academy Press; 2000. [3] Accreditation Council for Graduate Medical Education. Simulation and rehearsal. ACGME Bulletin 2005. December:1–32. [4] Musson DM, Helmreich RL. Team training and resource management in healthcare: current issues and future directions. Harvard Health Policy Review 2004;5(1):25–35. [5] Joint Commission on Accreditation of Healthcare Organizations. Sentinel event alert. Joint Commission on Accreditation of Healthcare Organizations, 30. Oak Brook (IL): JCAHO; 2004. [6] Issenberg BS, McGaghie WC, Hart IR, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999;282(9):861–6. [7] Devitt JH, Kurrek MM, Cohen MM. Testing the raters: inter-rater reliability of standardized anaesthesia simulator performance. Can J Anaesth 1997;44(9):924–8. [8] McGaghie WC, Issenberg SB, Petrusa ER, et al. Effect of practice on standardized learning outcomes in simulation-based medical education. Med Educ 2006;40:792–7.

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[9] Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? Br J Obstet Gynaecol 2005;113:177–82. [10] Mann S, Marcus R, Sachs B. Lessons from the cockpit: how team training can reduce errors in the L&D. Contemp Ob Gyn 2006; January:34–45. [11] DeAnda A, Gaba DM. Unplanned incidents during comprehensive anesthesia simulation. Anesth Analg 1990;71:77–82. [12] Schwid HA, O’Donnell D. Anesthesiologists’ management of simulated critical incidents. Anesthesiology 1992;76:495–501. [13] Chopra V, Gesink BJ, de Jong J, et al. Does training on an anesthesia simulator lead to improvement in performance? Br J Anaesth 1994;73:293–7. [14] Schwid HA, Rooke GA, Michalowski P, et al. Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teach Learn Med 2001;13(2):92–6. [15] Chopra V, Engbers FH, Geerts MJ, et al. The Leiden anesthesia simulator. Br J Anaesth 1994;73:287–92. [16] Russo SG, Eich C, Barwing J, et al. Self-reported changes in attitude and behavior after attending a simulation-aided airway management course. J Clin Anesth 2007;19:517–22. [17] Morgan PJ, Cleave-Hogg D. A worldwide survey of the use of simulation in anesthesia. Can J Anaesth 2002;49(7):659–62. [18] Lighthall GK. The IMPES course: toward better outcomes through simulation-based multidisciplinary team training. In: Dunn WF, editor. Simulators in critical care and beyond. Des Plaines (IL): Society of Critical Care Medicine; 2004. p. 54–60. Copyright (c) Society of Critical Care Medicine. Reproduced by permission of the publisher. [19] Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27(1):10–28. [20] Hassan Z, Sloan P. Using a mannequin-based simulator for anesthesia resident training in cardiac anesthesia. Simulation in Healthcare 2006;1:44–8. [21] Harrison T, Kyle MD, Manser T, et al. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg 2006;103:551–6. [22] Fletcher GC, McGeorge P, Flin RH, et al. The role of non-technical skills in anesthesia: a review of current literature. Br J Anaesth 2002;88:418–29. [23] Fletcher G, Flin R, McGeorge P, et al. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003;90:580–8. [24] Gallagher CJ, Issenberg SB. Simulation in anesthesia. Philadelphia: WB Saunders; 2007. [25] Howard SK, Gaba DM, Fish KJ, et al. Anesthesia crisis resource management training. Aviat Space Environ Med 1992;63:763–70. [26] Gaba DM, Howard SK, Flanagan B, et al. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology 1998;89:8–18. [27] Weller J, Wilson L, Robinson B. Survey of change in practice following simulation-based training in crisis management. Anaesthesia 2003;58:471–3. [28] Salvodelli GL, Naik VN, Park J, et al. Value of debriefing during simulated crisis management. Anesthesiology 2006;105(2):279–85. [29] Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simulation in Healthcare 2007;2(2):115–26. [30] Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004;13(Suppl 1):i2–10. [31] Cooper JB. The role of simulation in patient safety. In: Dunn WF, editor. Simulators in critical care and beyond. Des Plaines (IL): Society of Critical Care Medicine; 2004. p. 54–60. Copyright (c) Society of Critical Care Medicine. Reproduced by permission of the publisher. [32] Gaba DM. Improving anesthesiologists’ performance by simulating reality. Anesthesiology 1992;76:491–4.