IntroductionSimulation in health care creates a safelearning environment that allowsresearchers and practitioners to test newclinical processes and enhanceindividual and team skills beforeencountering patients. Many simulationapplications involve mannequins thatpresent with symptoms and respond tothe simulated treatment, analogous toflight simulators used by pilots.

The Agency for Healthcare Researchand Quality (AHRQ) supportssimulation research through theAgency’s patient safety program. In2011, AHRQ funded 11 multi-yeardemonstration grants to evaluate the useand effectiveness of various simulationapproaches and the role they can play inimproving the safety and quality ofhealth care delivery. This fact sheetbriefly summarizes these new projects;each summary includes the project title,

principal investigator and organization,AHRQ grant number, project start andend dates, and a description of the focusand goals of the project.Simulation has the potential to improvethe safety of health care by allowinghealth care practitioners to acquirevaluable experience, in a variety ofclinical settings, without puttingpatients at risk. These newly fundedprojects will inform providers, healtheducators, payers, policymakers,patients, and the public about theeffective use of simulation in improvingpatient safety.

The mission of AHRQ is to improve the quality,safety, efficiency, and effectiveness of healthcare by:

• Using evidence to improve health care.

• Improving health care outcomes throughresearch.

• Transforming research into practice.

Improving Patient SafetyThrough SimulationResearch: FundedProjects

F A C T S H E E T

Advancing Excellence in Health Care • www.ahrq.govAgency for Healthcare Research and Quality

Simulation allows health carepractitioners to acquire theskills and valuable experiencethey need safely, in a variety ofclinical settings, without puttingpatients at risk.

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Project DescriptionsImmersive Simulation for Design andEvaluation of an EmergencyDepartment IT Principal Investigator: Ann Bisantz,PhD, State University of New York atBuffaloAHRQ grant HS20433; Project periodApril 1, 2011 – March 31, 2014Emergency departments can be noisyand confusing places where keepingtrack of patients can be a challenge. Thegoal of this project is to design and testa prototype emergency departmentinformation system with the potential totrack ED patients and improveefficiency and safety, decrease ED waittimes, and decrease preventable injuriesto patients. The research team will usesimulation and cognitive systemsengineering methods to design and testprototype ED information systems thatare based on an in-depth understandingof the activities of caregivers and staffwithin the ED. They will use a multi-phase strategy to model key aspects ofED activities, iteratively developprototypes, and assess prototypes in asimulated clinical environment.Findings from this project will helpinform EDs as they implementelectronic information systems.Improving Pediatric Resuscitation: ASimulation Program for theCommunity EDPrincipal Investigator: Linda L. Brown,MD, Rhode Island Hospital,Providence, RIAHRQ grant HS20286; Project periodApril 1, 2011 – March 31, 2014Pediatric emergencies with criticalconsequences are an infrequentoccurrence in community hospitals, andbecause they are rare, medical teams inthese hospitals have very fewopportunities to perfect their skill inpediatric resuscitation. This research

team will use in situ medical simulationto assess the ability of Rhode Island’scommunity emergency departments(EDs) to perform pediatricresuscitations. They aim to develop asimulation-enhanced educationalintervention to improve the skills of EDstaff members and optimize the systemsrequired to perform pediatricresuscitations effectively. The projectincludes the implementation of astatewide, simulation-enhanced,evidence-based education interventionand an evaluation of the effectivenessand sustainability of the interventionthrough ongoing assessments and reviewof actual patient care.Improved Patient Safety bySimulator-Based Training in CardiacSurgeryPrincipal Investigator: Richard H. Feins,MD, University of North Carolina atChapel HillAHRQ grant HS20451; Project periodMay 1, 2011 – April 30, 2014In today’s high-stakes operating room,there often is insufficient time forresidents to learn surgical techniques byapprenticeship, practice their skills, andlearn how to deal with adverse events.The focus of this project is todemonstrate that training in cardiacsurgery techniques can be improved bycombining cardiac surgery simulationtechnology with a rigorous, simulation-based curriculum. The researchers willassess the effectiveness of usingsimulator-based training in componenttasks of cardiac surgery and overallprocedures based on six modules: threetypes of cardiac surgery and threesignificant adverse events that can occurduring cardiac surgery. They willemploy a computer-controlled, tissue-based cardiac surgery simulator that hasbeen shown to realistically duplicate anactual patient undergoing cardiacsurgery. Eight institutions will

participate in the study. While theproject focuses on cardiac surgeryresidents, the results potentially couldapply across a broad spectrum ofsurgical practice.Improving Patient Safety ThroughLeadership and Team Performance inSimulationsPrincipal Investigator: RosemarieFernandez, MD, University ofWashington, Seattle, WAAHRQ grant HS20295; Project periodJuly 1, 2011 – June 30, 2014Team leadership and team compositionare two important mediators of medicalemergency team performance that havenot been studied in patient safetyresearch. This project uses a 2 x 2(unfamiliar vs. familiar teams andleadership training vs. control) researchdesign to evaluate the impact ofleadership training and teamcomposition on ad hoc medicalemergency team performance. Ad hocmedical emergency teams will compriseemergency department nurses andphysicians from multiple hospitals. Theprimary outcome measure is teamperformance, which will be assessedusing a validated simulation-basedresearch platform (scenario + teamprocess measures + patient caremeasures). Acceleration to Expertise: Simulationas a Tool to Improve the Recognitionof SepsisPrincipal Investigator: Gary L. Geis,MD, Children’s Hospital MedicalCenter, Cincinnati, OHAHRQ grant HS20455; Project periodApril 1, 2011 – March 31, 2014Sepsis is a diagnostic challenge and aleading cause of death worldwide.Failure to recognize the early signs andsymptoms of sepsis and instituteaggressive management significantlyincreases the risk of death for children

and adults. The central hypothesis ofthis project is that simulation-basedtraining can accelerate the developmentof expertise needed by novice cliniciansto quickly and accurately recognizesepsis. By identifying the uniqueelements of the expert’s approach tosepsis, an effective, simulation-basedapproach might become possible.Specifically, the research team will: (1)determine the behaviors thatcharacterize and differentiate the expertfrom the novice in the recognition ofsepsis at the bedside and (2) developand implement simulation-basedlearning interventions that accelerate thedevelopment of expertise in relation tosepsis recognition. Using Simulation for TeachingFemoral Arterial Access: A Multi-Centric Collaborative ApproachPrincipal Investigator: Hitinder S.Gurm, MD, University of Michigan atAnn ArborAHRQ grant HS20447; Project periodApril 1, 2011 – March 31, 2014Vascular complications occur inapproximately 3 percent of patientsundergoing coronary intervention andare associated with significant morbidityand mortality. An increase in vascularcomplications corresponds with thebeginning of the academic cycle, andtrainees have more complications intheir first few procedures than laterwhen they are more experienced. Thisresearch team will develop andimplement a simulator to teach femoralartery access using a three-stepapproach: (1) development of a validsimulation model that provides realistictraining for obtaining femoral arterialaccess, (2) creation of a program toincorporate the simulation model in theeducational curricula of cardiologyfellowships at four major institutions,and (3) collection of followup data to

assess changes in complication ratesacross the institutions. Improving Physician and NurseCommunication with Serious GamingPrincipal Investigator: Mary E. Mancini,PhD, University of Texas, ArlingtonAHRQ grant HS20416; Project periodApril 1, 2011 – March 31, 2014Communication between physiciansand nurses often is less effective than itcould be, and ineffective interpersonalcommunication has been identified as aleading contributor to preventableadverse events. Physicians and nursestraditionally receive little if any directexperiential training in communicatingeffectively with each other, andtraditional methods for teachingcommunication skills often are bothtime-consuming and ineffective. Theseresearchers will develop and evaluate a“serious” game to improve thecommunication skills of practicingphysicians and nurses by increasing theirunderstanding about the impact ofineffective interpersonal and inter-professional communication. The gamewill allow users to experiment with andlearn more effective communicationskills and behaviors through practiceand feedback. Improving Cancer Care Patient SafetyThrough Pathology TrainingSimulationPrincipal Investigator: Stephen S. Raab,MD, University of Washington, Seattle,WAAHRQ grant HS20339; Project periodMay 1, 2011 – April 30, 2014Uncontrolled variability in diagnostictesting contributes to high rates of errorand increased costs. The incorporationof simulation training in pathologyresidency holds promise for reducingvariability. This research will determinewhether a simulation-based anatomicpathology education combined with

Lean methods of quality improvementis better than a traditionalapprenticeship for reducing errors informulating pathology diagnoses ofcancer in major solid organs. Theresearch team will conduct a doublecohort case-control study in a singleinstitution by separating residents onthe university hospital anatomicpathology rotation into two groups: (1)an integrated Lean-simulation-basedanatomic pathology education track and(2) a traditional apprenticeship track.They will compare resident performanceand patient safety outcomes in oncologyfor the two tracks over a 3-year period. Improving Patient Safety Related toMedication Infusion PumpTechnology Using SystemsEngineeringPrincipal Investigator: Alan D. Ravitz,MS, Johns Hopkins University,Baltimore, MDAHRQ grant HS20460; Project periodMay 1, 2011 – April 30, 2014Clinicians are well aware of thedifficulties of using medication infusionpumps and the associated threats topatient safety, and they often adapt theiractivities to the cumbersome design ofthe infusion pump, rather than havingaccess to machines designed to meettheir needs. To address theseshortcomings, this research team will:(1) define clinician requirements in theuse of medication infusion pumps anddevelop measures of effectiveness andperformance, (2) develop a rapidprototype environment to test thesafety/usability of simulated infusionpumps and develop prototypes based onclinician requirements using systemsengineering best practices, and (3)measure the safety and usability profileof infusion pump designs in a simulatedintensive care unit setting.

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A Secondary Task for MeasuringLaparoscopic SkillPrincipal Investigator: Mark W. Scerbo,PhD, Old Dominion University,Norfolk, VAAHRQ grant HS20386; Project periodSeptember 30, 2011 – September 29,2013Laparoscopic surgery imposes significantvisual-motor and attentional challengeson the surgeon, potentially puttingpatients at serious risk. Althoughclinicians can use simulators to practicetheir skills outside the operating room,there is no standard method todetermine whether a surgeon hasachieved or maintained laparoscopicproficiency. The objective of this projectis to validate a new secondary task thattargets the spatial skills needed tomentally translate 2-D display imagesinto the 3-D operational space. Theresearchers will use laparoscopicsimulators, porcine models, and freshcadavers to demonstrate that thesecondary task can be used to measurecharacteristics of laparoscopic skill.Successful demonstration of thehardware/software system and objectiveassessment methods hold good potentialfor coupling to any spatial task wheresurgeons use a video display to monitortheir activities.

Creating Simulation-BasedPerformance Assessment Tools forPracticing PhysiciansPrincipal Investigator: Matthew B.Weinger, MD, Vanderbilt University,Nashville, TNAHRQ grant HS20415; Project periodApril 1, 2011 – March 31, 2014Assurance of physicians’ ability to detectand manage uncommon but potentiallylethal events is an area of particularconcern for which simulation-basedperformance assessment may be ideallysuited. To test this approach, theresearchers will: (1) developstandardized, generalizable simulationscenarios and associated tools toconduct simulation-based assessment ofboard-certified anesthesiologists, (2)demonstrate that simulation-basedclinical assessment can be reliablydelivered across multiple national sitesto evaluate board-certified physiciansseeking recertification, (3) describe thedistribution of clinical performanceduring simulation, and (4) begin toaddress the remaining challenges andquestions related to reliable and validsimulation-based assessment ofpracticing physicians’ clinicalcompetency.

More InformationFor more information about the Agencyfor Healthcare Research and Quality,please visit the AHRQ Web site athttp://www.ahrq.gov. For more specificinformation on AHRQ’s researchpriorities and funding opportunities,please visit http://www.ahrq.gov/fund/. For specific programmatic questionsabout simulation research and otherpatient safety topics, please contact:Kerm Henriksen, PhDAgency for Healthcare Research andQuality540 Gaither RoadRockville, MD 20850Phone: 301-427-1331Email: Kerm.Henriksen@ahrq.hhs.gov

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www.ahrq.govAHRQ Pub. No. 11-P012-EF

September 2011