In Situ Simulation


In situ simulation is simulation that takes place in the actual working environment and involving those who work there

  • it is distinct from ‘center-based simulation’, which takes place in a simulation center separate from the work environment
  • In situ simulation does not specify whether simulation takes place in actual patient care spaces or in a location in the workplace that is not actually used for patient care (e.g. a simulation area within the workplace)

In situ simulation:

  • can involve any simulation modality (e.g. mannikin-based, simulated patients, task trainers, hybrid simulations)
  • may be high or low fidelity
  • can be scheduled or performed impromptu (with appropriate prebriefing)
  • ideally involves authentic teams (i.e. the participants perform their usual roles in teams with people they actually work with)


Simulation-based learning is a widely accepted educational technique supported that does not put patients at risk and is supported by educational theory.

The theoretical basis for performing simulation in situ is further supported by:

  • Situativity theory – learning is facilitated by the context of the experience
  • Systems Engineering Initiative for Patient Safety (SEIPS) model – in situ simulation can provide information on the obstacles and facilitators affecting the five interconnected elements of the work system that impact patient care processes and outcomes: person, tools/technology,) tasks, physical environment; and organisational characteristics. The technique can also be used to test changes.

In situ simulation has a growing evidence base (see below)


  • improving team performance in the workplace, including individual performance within a team and familiarity with equipment and the environment
  • identifying and mitigating threats to patient safety
    • e.g. latent safety threats are “system based threats to patient safety that can materialize at any time and are previously unrecognized by health- care providers or hospital administration” (Petrosoniak et al, 2016)
  • improve protocols, systems and infrastructure



  • enable learners to learn about the environment they work and the processes in place (e.g. location of airway trolley)
  • learners are more comfortable in their own environment
  • the environment is realistic (i.e. identical to reality)
  • less detail needed for prebriefing regarding the environment as it is already familiar to learners
  • easier and more accessible for busy participants, with minimal travel time
  • an expensive dedicated facility is not required
  • if families are appropriately informed they often feel more confident when they see staff practising simulations
  • free for participants
  • can reveal local system errors and latent threats (e.g. location of difficult airway trolley)
  • easy to tailor simulation to case mix and sentinel events that have occurred in the workplace
  • can be used to introduce guidelines and protocols
  • improve teamwork and inter-professional communication using teams that actually work together
  • easy to follow up (e.g. re-run simulation until participants perform well)
  • can have repeated scenarios that build upon one another (e.g. follow a ‘patient journey’ over time)


  • participants may be interrupted by pagers and phone calls or called away
  • psychological safety can be harder to maintain (e.g. lack of privacy and lack of space for confidential debriefing)
  • lower physical fidelity and lacks effects that can be used in a Sim Center (e.g. smoke machine)
  • time and cost of setting up and taking down elaborate simulations
  • faculty may lack experience and training compared to Sim Center faculty
  • more difficult to implement technology for video and other basic systems
  • potential for inadvertent use of simulation props (e.g. mock drugs or defibrillator) on real patients
  • cost of using real equipment and supplies (if used), and discrepancy with people’s inclination to avoid ‘wasting’ resources
  • potential safety issues (see below)


Potential risks

  • Inadvertent administration of simulated medications to real patients (medications used may be expired, artificial e.g. tap water, contaminated eg. food colouring or mislabelled e.g. real drug used with label changed (not advised!)
  • Simulation equipment or supplies used in clinical situations — these may have been modified, or be nonworking, obsolete, or unfamiliar
  • Contamination of equipment from the clinical environment used in simulation
  • clinical resources may be used at they same time they are required on real patients
  • lack of authenticity may lead to errors in learning (e.g. learners may observe behaviours that are not debriefed or learn procedures incorrectly due to modifications required for interaction with a mannikin)
  • Psychological impact on families in the nearby clinical environment (e.g. if hear laughing, or not understand there is a simulation taking place)

Approaches to maintaining safety

  • Faculty training and certification in simulation and hazards
  • Equipment
    • Establish an immediate restocking process if any operational equipment or supplies are used
    • Label equipment and supplies ‘for simulation only’ or ‘not for human use’; however:
      • there is no standard font, colour or verbiage for this
      • under stress people often don’t read labels correctly
      • forgetting to label something may lead to the assumption that it is safe for use
    • Employ strict cleanup procedures and use checklists
  • Medications
    • ‘‘Simulation only’’ labelling
    • Alternative use real medications and employ medication accounting
    • Beware of using expired medications
    • Secure locking
    • Cleanup procedures
  • Develop policies and procedures to ensure patient safety
    • Determine what equipment and supplies to use
    • Determine who has access to the simulation space and storage
    • How equipment and supplies should be processed after use and securely stored
    • Contingency planning
  • Participants and patients
    • Awareness and transparency
    • Clear warnings in prebrief and at the end of the simulation (e.g. to empty pockets and not remove anything from the sim room)
    • Use safety signs/ posters
    • Brief everyone in the nearby environment (e.g. patients and their families)


Encourage participation

  • obtain and develop unit-wide support and “buy in” (may require a change management process)
  • emphasize objectives of teamwork and systems improvement
  • emphasize it is not an individual assessment but a learning opportunity
  • provide incentives for participation (e.g. coffee)

Boost patient and staff perceptions

  • notify staff and participants of objectives and expectations
  • brief patients in the vicinity that a simulation will take place (so that they don’t think someone is dying in the adjacent bed space!)
  • implement a feedback process for participants
  • feedback to staff the improvements and solutions that have been created using in situ simulation

Improve feasibility

  • allow sufficient time for preparation (it can take over your life!)
  • organize equipment to allow rapid set up and take down of scenarios
  • be flexible and sensitive to unit workload (e.g. may need to cancel when the unit is busy; plan for times of low-volume workload)
  • establish a priori cancellation criteria (number of patients in the unit, provider-to-patient ratios)
  • conduct simulations near handover periods where there is an overlap of staffing
  • ensure simulation sessions and debriefs are brief and focussed

Improve educational effectiveness

  • ensure faculty are trained in simulation and debriefing
  • ensure adequate prebrief (establishing ground rules and orientation to scenario and equipment
  • integrate with curriculum
  • use unit-specific scenarios
  • impromptu simulation must still have appropriate prebriefing of those involved (e.g. notification of code team that a simulated code will take place in the near future)
  • tailor physical fidelity to the needs of the scenario to meet the learning objectives

Address latent safety threats

  • integrate with quality improvement and risk management systems
  • repeat scenarios to determine if solutions are effective

Address safety issues (see above)

  • employ safety measures as above


Patient outcomes

  • An observational study by Andreatta et al (2011) found that survival rates for cardiopulmonary arrest in a North American paediatric hospital increased to approximately 50% (p = .000), in correlation with an increased number of mock codes (r = .87). The results held steady for 3 consecutive years and exceeded national averages. However, the study design cannot establish causation.

Team performance

  • Steinemann et al (2011) did a before-and-after study of in situ-based trauma team training of 5-8 people who underwent 4 hours of training consisting of 1 hour of didactic teaching then a programme of 3 x 15 minute scenarios over 3 hours. Teamwork ratings, task speed and task completion rates improved within the simulations. Observation of 244 real-life blunt trauma resuscitations for six months before and after training showed that these benefits translated into clinical practice.
  • Miller et al (2012) used a pre-/post-observational design using multidisciplinary in situ simulation at a Level 1 trauma centre translated to improvements during real trauma resuscitations across 12 of 14 non-technical skill components (e.g. teamwork, situational awareness, prioritisation), though only communication showed statistical significance. Four phases were studied pre-intervention (baseline), followed by didactic-only, in situ trauma simulation, then a potential decay phase. The improvements seen between baseline and the in situ trauma simulation phase were not sustained during the decay phase (when in situ simulation was ceased) and no significant difference could be demonstrated between the didactic and in situ trauma simulation phases.
  • A systematic review by Rosen et al (2012) found 29 studies of in situ simulation, and suggested positive impacts on learning and organizational performance. However, simulation design, delivery and evaluation methods varied greatly and overall the studies were generally low quality.
  • Theilen et al (2013) performed a prospective cohort study of all deteriorating inpatients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of a MET and concurrent team training. They found significantly improved recognition and management of deteriorating in-patients with evolving critical illness.
  • Kobayshi et al (2013) employed a prospective in situ simulation intervention incorporating human factors engineering to improve arrhythmia detection within the ED: arrhythmia detection rates increased from 5 to 55%.

Latent safety threats and system improvement

  • Patterson, et al (2013) studied 90 in-situ simulation events in an urban ED over a 12 month period and found that a latent safety threat was identified at a rate of one in every 1.2 simulations performed. This compared favourably with lab-based simulation sessions that identified a latent safety threat at a rate of one in every 7 simulations performed.
  • Kobayashi et al (2006) used an in situ simulation programme to test a new ED within an academic hospital and orient a multidisciplinary team to the facility using multiple scenarios. Significant operational issues identified by participants were corrected before opening of the facility. However, benefits in the orientation of participants over non-simulation methods could not be proven.

References and Links

Journal articles

  • Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med. 2011 Jan;12(1):33-8. doi: 10.1097/PCC.0b013e3181e89270. PubMed PMID: 20581734.
  • Calhoun AW, Boone MC, Peterson EB, Boland KA, Montgomery VL. Integrated in-situ simulation using redirected faculty educational time to minimize costs: a feasibility study. Simulation in healthcare. 6(6):337-44. 2011. [pubmed]
  • Cheng A, Grant V, Auerbach M. Using simulation to improve patient safety: dawn of a new era. JAMA pediatrics. 169(5):419-20. 2015. [pubmed]
  • Durning SJ, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Medical teacher. 33(3):188-99. 2011. [pubmed]
  • Kobayashi L, Shapiro MJ, Sucov A, et al. Portable advanced medical simulation for new emergency department testing and orientation. Academic emergency medicine. 13(6):691-5. 2006. [pubmed]
  • Kobayashi L, Parchuri R, Gardiner FG. Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias. BMJ quality & safety. 22(1):72-83. 2013. [pubmed]
  • Miller D, Crandall C, Washington C, McLaughlin S. Improving teamwork and communication in trauma care through in situ simulations. Academic Emergency Medicine. 19(5):608-12. 2012. [pubmed]
  • Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013 Jun;22(6):468-77. doi: 10.1136/bmjqs-2012-000942. Epub 2012 Dec 20. PubMed PMID: 23258390.
  • Patterson MD, Blike GT, Nadkarni VM. In Situ Simulation: Challenges and Results. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. Available from: http://www.ncbi.nlm.nih.gov/books/NBK43682/
  • Petrosoniak A, Auerbach M, Wong AH, Hicks CM. In situ simulation in emergency medicine: Moving beyond the simulation lab. Emergency medicine Australasia : EMA. 2016. [pubmed]
  • Raemer DB. Ignaz semmelweis redux? Simul Healthc. 2014 Jun;9(3):153-5. doi: 10.1097/SIH.0000000000000016. PubMed PMID: 24401925.
  • Rosen MA, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ. In situ simulation in continuing education for the health care professions: a systematic review. J Contin Educ Health Prof. 2012 Fall;32(4):243-54. doi: 10.1002/chp.21152. Review. PubMed PMID: 23280527.
  • Schroedl CJ, Corbridge TC, Cohen ER. Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial. Journal of critical care. 27(2):219.e7-13. 2012. [pubmed]
  • Steinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, Oliver C, Ho HC, Speck C. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ. 2011 Nov-Dec;68(6):472-7. doi: 10.1016/j.jsurg.2011.05.009. Epub 2011 Aug 3. PubMed PMID: 22000533.
  • Surcouf JW, Chauvin SW, Ferry J, Yang T, Barkemeyer B. Enhancing residents’ neonatal resuscitation competency through unannounced simulation-based training. Medical education online. 18:1-7. 2013. [pubmed]
  • Theilen U, Leonard P, Jones P. Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. Resuscitation. 84(2):218-22. 2013. [pubmed]
  • Walker ST, Sevdalis N, McKay A, Lambden S, Gautama S, Aggarwal R, Vincent C. Unannounced in situ simulations: integrating training and clinical practice. BMJ Qual Saf. 2013 Jun;22(6):453-8. doi: 10.1136/bmjqs-2012-000986. Epub 2012 Dec 4. PubMed PMID: 23211281.
  • Weinstock PH, Kappus LJ, Garden A, Burns JP. Simulation at the point of care: reduced-cost, in situ training via a mobile cart. Pediatr Crit Care Med. 2009 Mar;10(2):176-81. doi: 10.1097/PCC.0b013e3181956c6f. PubMed PMID: 19188878.

FOAM and web resources

MIME 700 2



Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

One comment

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.