Human Factors in Medical Simulation

Function

From a healthcare perspective, the primary goal of HFE becomes the optimization of technology and care system design to achieve productivity, safety, efficiency, and quality in the care delivery process.[4] Secondarily, this science works to enhance the well-being (experience, joy, satisfaction, health, and safety) of anyone (patient, staff, or visitor) who interacts with the system.[5] To this end, a recent addition to human factors (HF)-based methodologies is "human-centered design." When effectively applied, the following elements are demonstrated through this approach [1]:

1. An explicit understanding of each system component (users, tasks, and environments)
2. End-user involvement throughout the process
3. Iterative refinement
4. Reflective of user-centered evaluation
5. Inclusion of the entire user experience
6. Incorporation of multidisciplinary perspectives

Through the use of mixed-methods research, healthcare simulation can provide a platform on which to evaluate the impact of organizational design/policies/procedures on individual or team performance and safety through the human-centered design approach.[4] Functional task alignment is achieved by matching the objectives of the simulation session to the delivery format, modality, and location. HF evaluation tools are incorporated into structured debriefing sessions to identify latent safety threats (LST) and elucidate model behaviors for future PDSA cycles. This approach can replicate complex clinical situations while maintaining a safe environment for errors, reflection, and growth. As a result, simulation is transformative in its ability to explore frameworks and then test and embed improvements. When applied to HFE foci (Cognitive Engineering, Heuristics and Decision Making, Communication, Perception and Performance, Safety, Training, Usability), simulation creates the synergism necessary to effectively "fit the system to the human." [1]

Issues of Concern

A recent systematic review highlighted successful simulation applications for human factor skills (HFS) training and evaluation. This approach is especially beneficial in critical care settings and situations with high acuity and low occurrence.

Improvement has been demonstrated when HFS are taught in conjunction with technical skills, but it is most clearly aligned when HFS are taught by themselves. For optimal impact, future research endeavors should consistently be explicit in describing which behavioral markers are being assessed and with which instruments. Outcome validity is further supported when a multimodal educational design is paired with a blinded assessment of video-recorded performance. Recommendations also included expanding studies to include assessments of attention skills, day-to-day applications of HFS, and how exactly transfer to practice is being measured. [6]

Immersive learning environments such as those supported by artificial intelligence (AI) and virtual and augmented realities (VR and AR) demonstrate significant potential to support HFs simulation with their ability to simulate realistic experiences in cyber environments or synchronized digital overlays in the authentic environment. To address limitations with simulating psychomotor skills, some developers have incorporated pseudo-haptics, where audio (drill sounds) and visual cues (cursor speed) create the illusion of expected kinesthetic cues. Others facilitate embodiment and potential skill transfer by combining pseudo-haptics with a virtual hand experienced in the first-person perspective. The addition of software platforms that offer self-authoring and low-coding scenario development has increased customizability for participants, decreasing the likelihood of learner disengagement with static or predictable scenarios. These advancements allow individualized deliberate practice in safe settings to support mastery of skill acquisition. [7]

In a study comparing an AI-powered tutoring system comprised of audiovisual metric-based feedback with scripted debriefing (VOA) via remote expert instruction, they examined instructional effectiveness (as measured by simulated procedural completion) and participant cognitive and affective responses. The personalized responsiveness of the VOA platform allowed a spectrum of learner levels to receive personalized formative feedback. Students in the VOA group were more aware of their metrics and goals, which enabled them to set measurable performance objectives and achieve higher expertise. Furthermore, although participants in the instructor-led group reported stronger positive deactivating emotions, this supportive learning environment did not result in more expert performance. Over the 13-week study, the use of the AI system demonstrated a cost savings of 53 expert facilitator hours, with comparable OSAT scores between the groups. [8]

AI-supported simulation enables one to acquire non-technical skills, including communication and medical decision-making. Simulations incorporating Big Data Analytics allow the collation of medical histories, demographics, genetics, and digital imaging to create realistic patient presentations. These data sources also inform disease prognosis and treatment responses based on participant interactions within the scenarios. Simulation systems utilizing machine learning algorithms can analyze simulation participant data to identify institutional trends, as well as opportunities for modeling best practices or areas of improvement. [7] The synergism attained through AI and simulation beyond the training context has also been demonstrated. In one study using simulation to generate patient encounters, researchers evaluated a proposed error classification system as applied to 2 generative AI system stages: input - a patient-facing large language model (LLM), and output - an ambient digital scribe (ADS). This assessment demonstrated that omission was the most frequent generative AI error, accounting for 42% of the LLM errors and 83% of those in the ADS scenarios. With the rapid pace of the virtual learning environment and AI-enabled technology development, simulation will be a critical step for ensuring safe application in the healthcare environment. [9]

Curriculum Development

Studies using simulation-based HFS skills training have been published describing formative assessment in multiple different professions (emergency medical services, nursing, medicine), disciplines (emergency medicine, adult, pediatric and neonatal critical care, neurology, gastroenterology, anesthesiology, general surgery, trauma, otolaryngology, psychiatry) and ancillary services (pharmacology, infection prevention and control, social work, and law enforcement).  Simulation for summative assessment most frequently involves using Standardized Patients or partial task trainers to evaluate individuals in one profession in their initial stages of training. There is currently a lack of readily available assessment tools with the validity and reliability to meet the rigorous recommendations for summative assessment.[10] More detailed descriptions of specific simulation-based interventions are included in the following sections.

Procedural Skills Assessment

Within healthcare education, HFS are often described as either technical or non-technical. Technical skills generally refer to the medical and procedural knowledge necessary for delivering competent patient care. [11] The following are some technical skills that span multiple specialties:

Individual Procedural Skills

Collaborative efforts between infection prevention/control (IPC), HPE, and in-situ simulation have been identified as prime foci for preparedness improvement initiatives. After initiating practical/virtual workshops, investigators from the Alberta Health Services group evaluated patient care simulations at the IPC–system interface to target LST surrounding the use of personal protective equipment. By utilizing structured debriefings that incorporated checklists, hospital policies, and protocols, investigators were not limited to relying solely on an individual's process recall. The human limitations and individual differences identified through this process were subsequently incorporated into design modifications (logistically matching the supply cart to the "donning and doffing" guide) to improve the likelihood of safe and appropriate PPE use. [12] Central line placement and management strategies incorporating HFE principles through simulated training that have yielded reductions in the frequency of central line-associated bloodstream infections are another IPC application. [13]

Medication prescribing is an inherently error-prone healthcare delivery skill generalizable across clinical settings. Scenario-based simulations were integrated into a counterbalanced, crossover design study to assess the HFE-derived "communication-human information processing" model of medication prescribing. Researchers assessed usability, perceived workload, and error frequency concerning system alerts triggered during this process. After combining participant feedback with the efficiency linked to intrusive alerts, investigators redesigned the process, and a modestly significant reduction in workload was attained. [14] Medication preparation and administration can also be error-prone. Utilizing a modified Human Error Assessment and Reduction Technique during simulated sessions in the NICU, researchers evaluated medication administration reliability. Observers identified the following error-producing conditions: limited time to detect or correct label errors, lack of independent output checks, and distractions. Conversely, results suggested that labels created with an HCD focus reduced this likelihood by more than 40%. [15] A randomized crossover design compared standard labeling practices to light-linking infusion line technology in an adult ICU. Visual cues from the light linking technology reduced injection time overall, significantly so in low-light settings. Additional results included improved usability and reduced task load. [16]

Pattern recognition in healthcare involves incorporating various sources of information to identify trends that can aid in diagnosis, prognosis, and treatment planning.  Recognizing and integrating information regarding life-threatening conditions is paramount in the critical care setting. Mixed methods studies have highlighted the benefit of using simulation to evaluate HFE associated with clinical pattern recognition and intervention in these circumstances as well. [17] In the context of life-threatening arrhythmias, one prospective study used in-situ simulation in the emergency department to identify the limitations of a telemetry system. Insights gained regarding the physical/human-machine interactions and the organizational/human–organization interactions elucidated the process improvements necessary to address telemetry-based detection and appropriate dispositioning of patients with life-threatening arrhythmias. [18] 

Tool Development and Bundle Compliance

Simulation can be used for clinical assessment tool development and modification, as well as to optimize bundle customization and compliance.

Clinical Handoff: A systematic review of studies assessing clinical handover highlighted that multiple safety issues can be linked to suboptimal handoff performance. No ideal model was identified, though the most frequently studied tools were related to the Handoff CEX, and SBAR was the most commonly cited mnemonic. Standardized documentation and electronic templates were also frequently used to facilitate communication and care coordination. Outcomes indicated that role-play and simulation-based team training were better received than didactic approaches and more frequently associated with improved efficiency and effectiveness. Residents demonstrated skill transfer from the simulated to the clinical environment, reducing technical errors, critical information omissions, handover duration, and time-related tasks. Though the overall improvement in the health and well-being of patients and the positive impact are evident, opportunities remain to clarify precisely which behaviors constitute best practice. (17)

Endoscopy: Through collaboration between organizational, educational, and clinical leads, the Joint Advisory Group for Gastrointestinal Endoscopy developed the Improving Safety and Reducing Error in Endoscopy (ISREE) strategy. As part of this, their endoscopic non-technical skills (ENTS) program incorporated Simulation training in HFS. Simulation training resulted in an improvement in individual and team performance, as well as the ability to detect latent errors in the clinical environment [19]

Airway Management: Utilizing change ideas elicited during biweekly tabletop simulations based on the IHI model for improvement, a group from an adult ED developed a color-coded airway cart to reduce time to obtain difficult airway management equipment. The improvement concepts elicited during the debriefings translated into increased provider comfort after clinical intubations, as demonstrated by a 76% improvement from baseline (319 seconds down to 76 seconds) over 6 months. [20] The National Emergency Airway Registry for Children (NEAR4KIDS) Airway Safety Quality Improvement Bundle is a QI tool to improve the safety of tracheal intubations." A single-center retrospective study utilized translational simulation to optimize bundle customization. Assessments 9 months following the intervention resulted in statistically significant improvement in bundle compliance (93.7% with P < 0.001) and apneic oxygenation (77.9% with P < 0.001). [21] Similarly, in a multisite prospective mixed methods study, the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) collaborative utilized two simulated scenarios to evaluate pre-intubation checklist usability. Checklist usage resulted in the verbalization of 93% of items and a greater than 80% completion rate. Participant comments suggested that the checklist facilitated a shared mental model, helped to offload the team leader cognitively, and prompted contingency planning. [22] For ENT physicians, a Modified Delphi approach was used to develop an assessment tool for use during pediatric tracheostomy emergencies in the simulated and clinical environment.  This process resulted in a 22-item assessment tool incorporating 12 tracheostomy-specific items, 4 team and personnel items, and six equipment items, which could be used to generate additional QI initiatives. [23]

Medical Decision Making and Leadership Development

Non-Technical Skills

The following statement is a consensus-derived definition of non-technical skills: "A set of social (communication and teamwork) and cognitive (analytical and personal behavior) skills that support high-quality, safe, effective, and efficient inter-professional care within the complex healthcare system.[24] The Human Factor Skills for Healthcare Instrument represents an international, multidisciplinary collaboration to improve the assessment of HFS in the clinical setting. After undergoing an iterative approach to tool refinement, the final instrument was evaluated with 711 trainees. Its ability to assess self-efficacy in non-technical skills across multiple clinical professions was valid and reliable. [25]  When investigators adapted this tool to the non-clinical setting, it retained these features, with a Cronbach's alpha of 0.93. The final 12-item "Human Factors Skills for Healthcare Instrument-Auxiliary version" (HuFSHI-A) instrument demonstrated sensitivity to change after simulated training with a large effect size (p<0.0001 and d > 0.7, respectively)[26]

Communication

Of the ten HF foci considered most relevant for patient safety, the WHO identified "communication failure" as a significant and recurrent contributor to adverse events. They assert a clear relationship between communication skills, teamwork, and simulation-based medical education.[27] In high-acuity situations, increasing illness severity correlates with increased directive-style leadership. However, there remains ample opportunity to inform HFE and simulation literature regarding ideal leadership communication styles. Additional communication-related topics that are ripe for clarification include "outer-loop" communications, including how team members decide what items are "relevant" to the team leader or when the appropriate timing for team leader updates would be.[28] In one study utilizing inter-professional simulation to evaluate the response to neurologic emergencies, investigators identified concepts of clear communication. They highlighted approaches such as "stating the obvious," "announcing what you are doing," and "repeating information back" to ensure its accuracy. Further, while the development of a "flat hierarchy" was considered conducive to all team members being "heard," assertive communication was a requisite expectation of each team member's role to best support error prevention and other patient safety principles.[29]

Effective patient communication skills are also critical for leaders. Nursing professional development practitioners at a pediatric tertiary care center developed standardized patient simulations to train interdisciplinary healthcare providers in the assessment, identification, and intervention of adolescents at risk for suicide in any clinical setting. They supplemented existing curricula by integrating standardized patient simulations utilizing the HEEADSSS assessment to deliver communication-focused education. After this pilot, they demonstrated increased confidence, clinical competency regarding psychosocial interviews, and use of the HEEADSSS tool. Additionally, they were able to increase the number of social work referrals for modifiable risk factors of suicide.[30] 

Cognitive Load and Clinical Decision-Making

Simulated scenarios delivered in a pediatric ICU allowed researchers to evaluate 20 types of tasks surrounding the institution of multimodal monitoring. Structured debriefing included elements of HTA, CTA, and usability testing. In addition to providing insight into participant thought processes, the "think aloud" simulation method enabled investigators to provide insight to participants regarding the information available on the platform.  This study highlights the dichotomous ability of technology to either support or hinder technical tasks, as well as the utility of simulation methodology to support the HFE evaluation process.[17] Simulated outpatient encounters have also been used for usability testing between different ADS products.[31] 

Pediatric Hospitalists have described a framework for advancing QI and research regarding clinical decision support (CDS) tools. Traditional QI methodology, such as the 5 Why's, SEIPS model, is first used to define the clinical problem and understand the associated work system. Next, confirmation of alignment between the CDS and the desired improvements is achieved through developing CDS use metrics and carefully identified balancing and process-outcome measures. Simulation subsequently provides a platform for the iterative process of usability heuristics as representative groups of participants perform their workflow utilizing the CDS tool. Integrating assessment tools like The 5 "Rights" of CDS (information, time, person, channel, and format) into a structured debriefing process allows investigators to evaluate interface validity from the HCD perspective and to incorporate user feedback into the PDSA cycles of tool reiteration.[32] 

Situational Awareness

Leaders of high-performance teams also rely on the critical skill of Situational Awareness (SA). Three cognitive levels of SA include the perception of available information, the comprehension/interpretation of the perceived information, and the anticipation of future events based on this comprehension/interpretation. When used in the simulated setting, the Situation Present Assessment Method (SPAM) is a validated and reliable method for assessing SA by evaluating latency periods. After warning the participant of a pending "query," the latency between this warning and its acknowledgment is considered a measure of cognitive workload. However, the latency between the query and the answer is considered a proxy measure of SA.  By carefully crafting the timing and the content of the queries, each level of SA can undergo assessment.[33]  SA in a "Room of Improvement" training during a simulated ICU shift handover demonstrated improvement in actual detection rates and improved handling of patient safety hazards. This learning effect was sustained for 12 weeks, and the improved daily handling and discussion of errors translated to the clinical bedside. [34]

Team Leadership 

While no systematic reviews address team leadership assessment during a crisis, the Concise Assessment of Leader Management (CALM) Tool shows promise for use in simulated and real pediatric crises. Applying this tool to the video reviews of actual pediatric emergencies (cardiac arrests, septic shock), investigators demonstrated a statistically significant correlation between the CALM score and time to epinephrine administration (p = 0.01) and a positive correlation with time to fluid administration. However, the latter was not statistically significant (p = 0.64). [35]

Error and Risk Management

Combining generic and domain-specific medical error classification systems can address diverse educational needs. Through simulation, participants can experience and analyze events under controlled conditions, leading to the development of error mitigation and management strategies. The psychological safety and non-punitive culture of the simulated environment supports the view of errors as learning opportunities, further strengthening the overall safety culture in healthcare settings.[36]

From a "countermeasure" perspective, avoiding, capturing, and mitigating errors represent three patient safety lines of defense.  Simulation is most effective when there is adequate task alignment - the reproduction of required skills allows for the successful completion of the tasks.[37] With this in mind, one group created a low-cost, low-tech reproduction of psychological fidelity by creating an Escape Room to teach patient safety skills to medical students. This suitcase-sized, portable platform incorporated the clinical tasks of diagnosis, treatment, medication prescription, and calculation of an early warning score. Successful task completion was rewarded with the "codes" necessary to open additional padlocks within the suitcase, thus enabling progression through the simulated scenario.  Students successfully "escaped" the room by avoiding preventable harm to the patient. [38]

From an adverse event perspective, multiple different applications of simulation have been suggested to aid in the investigation and mitigation process, including:

1. Using the high-fidelity simulation of key activities, like an end-to-end major incident investigation, for emergency investigator training
2. Bringing relevant participants together from multiple organizations for testing, reviewing, and improving coordinated investigations to improve investigative infrastructure
3. Exploring contributory factors, developing and testing solutions through the simulated recreation of conditions/events underlying serious safety incidents.
4. Probing systems vicariously to uncover LST while applying Safety I and/or Safety II principles [39]

Continuing Education

IPE Facilitation and Competencies

Optimizing facilitator training and a structured approach is critical when delivering and debriefing interprofessional simulations. In order to develop structured facilitator guidelines, one group found that qualitative content analysis showed improvement when the debriefings had equitable involvement of nurses and physicians and more emphasis on teamwork and communication.[40] Similarly, thematic analysis demonstrated that interprofessional learning improved with these guidelines.  One study identified six basic competencies for simulation facilitators: "knowledge of simulation training, education/training development, education/training performance, HFs, ethics in simulation, and assessment."  For facilitators providing advanced levels of training, these additional five competencies were recommended: "policies and procedures, organization and coordination, research, QI, and crisis management." [41]

Clinical Significance

Team Training

From an educational perspective, transfer-appropriate processing occurs when the cues available during information encoding/memorization are the same as those expected to be available during memory recall. This approach requires a priori team task analysis to determine appropriate fidelity for task alignment for the task work skills related to individual performance and the teamwork skills (cognitive, behavioral, and attitudinal) representing the performance of the team as a whole.[37] For an assessment tool to be useful, its application to the task work or teamwork skills must be valid, reliable, sensitive, and feasible.

Multiple studies have focused on developing, evaluating, and refining assessment tools for teaching HFS in different environments. In 2019, a systematic review regarding the assessment of team function during a crisis addressed the validity and reliability of 13 tools. Similar teamwork domains were included across tools and settings, though the emergency department represented the most frequent site for simulated performance. Measurement evidence indicated that the Team Emergency Assessment Measure (TEAM) tool was the most promising. However, both the TEAM and the Modified Non-Technical Skills Scale for Trauma (T-NOTECHS) were validated for simulated and clinical resuscitation assessments [42]. [43] A subsequent systematic review in 2022 included 19 tools but supported the prior recommendation[44]

One review utilized the Action, Actor, Context, Target, Time (AACTT) framework to evaluate teamwork in the OR[45]. Investigators noted multiple teamwork interventions currently cited in the literature including checklists (e.g., Surgical Safety Checklists (SSC) tools to optimize communication (e.g., SBAR), frameworks (e.g., "Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™)"), and high-fidelity simulation training. Protocol interventions demonstrated superior specificity by offering clear roles, and focusing primarily on improving communication and reducing distractions. Clarity in role assignments improves accountabilty and collaboration in its ability to support shared mental models amongst interprofessional teams. SSC was referenced in 9.6% of the studies, though the descriptions did not consistently specify the actor or target. Investigators suggest that mapping the components of future checklists to the AACTT framework will improve the rigor of future studies.[46]

Optimized simulation-based team training can provide results that are translatable to patient outcomes. This concept is exemplified by the results of a prospective evaluation of the Medical Team Training program utilized by the Veterans Administration. Investigators identified a dose-response relationship between training and mortality. For every three months of training, there was a commensurate reduction of 0.5 deaths per thousand operations.[47] In an observational study of the impact of ward culture on the escalation of care, debriefing sessions revealed that explicit" permission to act" empowered staff to facilitate this process. By protecting training time, participant attendance at these sessions was greater than 95%.  The cost-benefit analysis revealed decreased PICU bed-associated costs by £801,600 per year (£2400 per day x 334 PICU bed days). Furthermore, these savings substantially exceeded the costs of regular team training. Investigators suggested that future research should include the financial impact on providers of "failure to rescue.[48] In a multicenter study evaluating training for IHCA response, survival rates were significantly higher for patients in hospitals with more active participation in simulation training (42.8% versus 31.8%; P less than 0.0001). This effect was valid for large and medium-sized hospitals and did not significantly change after adjusting for hospital-expected mortality through logistic regression. The adjusted OR of 0.62 (CI 0.54- 0.71; P less than 0.001), represented an additional 151 potential lives saved - a substantial benefit given a cost of only 1.1 additional simulation/100 beds/year/life saved.[49]

Just in Time/Just in Case

Commissioning during a pandemic presents its own unique set of challenges.[50] The Quadruple Aim - a set of 4 interdependent goals consists of (1) enhancing patient experience and safety, (2) improving population health, (3) reducing costs and preventing loss of revenue, and (4) improving wellness and satisfaction of health care workers, because excellent health care is not possible without a physically and psychologically safe and healthy workforce. The first is addressed using simulation to develop and test new technologies, equipment, and protocols. Readiness training through telehealth and remote simulation creates virtual platforms that support population health. Usability testing of equipment and computer-based systems helps support a reduction in lost revenue by anticipating system performance and resilience.

Preparedness training creates psychological safety and supports staff wellness and satisfaction. [51] 

Systems Integration Simulations

Simulation-based hospital design and clinical system testing (SbHDT and SbCST) have recently been employed to evaluate new and repurposed clinical spaces. Methods including tabletops, full-scale mockups, and systems integration simulations are now incorporated during a project's preconstruction, post-construction, and moving/commissioning phases.  One structured debriefing framework is Promoting Excellence And Reflective Learning in Simulation" (PEARLS) for System Integration  - an amalgamation of standard debriefing methods with an updated facilitation script to focus on identifying systems issues and maximizing continuous improvement efforts. [52] SAFEE (Summarize, Anchor, Facilitate, Explore, Elicit) is a debriefing guide based on the Agency for Healthcare Research and Quality and Center for Health Design principles for SbHDT to evaluate systems in the context of the architectural design of the built environment. [53]

SbHDT in the schematic design phase helps mitigate the costs of any identified LST early in the project.  Using a full-scale cardboard mockup to simulate 11 clinical areas in a 400-bed freestanding children's hospital.  Debriefing sessions involving frontline participants yielded concerns that were categorized and prioritized through failure modes and effects analysis (FMEA) and shared with the architect team.  Design changes were validated during a second round of simulations, resulting in a statistically significant reduction in criticality scores, especially those of higher severity.[54] Of the 722 LST identified during simulations, 57% were able to be addressed prior to the build, resulting in a cost avoidance of $90 million. Post-construction modification would have been cost-prohibitive for 28% of the findings. For $1.6 million (0.01% of the overall project expenditure), SbCST represents a significant savings. [55] Executive team members at a different institution used this objective, user-informed approach to analyze the current state of a passageway to determine the risk-benefit ratio of creating a new throughway. Interprofessional critical care participants evaluated two simulations, with debriefing notes informing FMEA. Feedback prompted the multimillion-dollar project to build the new connector to improve integrated care and transport. [56] 

Another set of investigators used video-recorded simulations to develop a quantitative assessment instrument that compares LST in preconstruction vs. clinical environments. Full-scale mockups of PICU and NICU rooms included static design features such as drywall, patient care booms, medical gas ports, entries, exits, and outlets. Audiovisual equipment positioning was optimized to provide unobstructed views and sound capture at critical locations, including the simulated patient's airway, foot of bed, and the code cart. LST in both environments were observed and stratified into hazard categories, with operational definitions that were iteratively refined by an interprofessional team with clinical and HFE expertise. This process resulted in the six categories comprising the Hazard Assessment and Remediation Tool (HART), which are to be used for subsequent video assessments by pairs of clinical and non-clinical reviewers. The HART instrument demonstrated excellent agreement with an overall IRR of 0.89% (95% confidence interval [0.843, 0.929]). Individual item IRR ranged from 0.76 for "obstructed path" to 0.93 for "obstructed access to the patient." "Infection risk," "poor visibility," "slip/trip/fall/injury," and "obstructed access to equipment" measured 0.92, 0.91, 0.89, and 0.88, respectively. With high IRR and in situ simulation comparison, the HART instrument enhances SbCST methods by providing a quantitative measurement to assess multiple iterations of preconstruction design modifications. [57]

In the post-construction setting, using SbCST with FMEA still retains the utility of proactively identifying LST in a newly constructed hospital. Threats were categorized and prioritized for remediation. Reassessment through simulation after countermeasure implementation demonstrated that 76% of these issues could be mitigated before commissioning. Investigators suggest that combining SBCST and FMEA with subsequent systems testing could be considered a new standard for proactively identifying and managing construction and commissioning-related risks. [58] Similarly, SbCST was performed to evaluate issues around an interventional trauma OR. Evaluation foci included two transport routes, OR switching capabilities, and equipment use for LST during the transport of an exsanguinating trauma patient. In addition to debriefing and observation, metrics regarding time, distance, equipment count, and route considerations were collected. The identified threats led to improved C-arm use, time reductions, and a new process for changing OR table tops[59]. During the pre-move phase of a neonatal intensive unit transitioning from an open bay format to a single-family room design, investigators found that staff engagement in new process development increases enthusiasm and preparedness for impending changes. [60] 

SbCST also has applications in well-established environments.  Comparison of LST at multiple sites across a health system highlighted common opportunities for mitigating safety threats. Theme identification may even be generalizable for readiness efforts of hospitals unable to participate in the simulations.  The holistic perspective of this approach provides leaders with the necessary data to prioritize LST, appropriately allocate resources, and track the effectiveness of countermeasure implementation. [61] 

Pearls and Other Issues

1. In addition to using QI to reduce errors, HFE principles can be used to optimize and sustain safety approaches. 
2. To optimize the impact of simulation-based training, use functional task alignment to meet objectives with a structured debriefing in a psychologically safe environment to facilitate reflection.
3. Combine didactics and workshops with simulation-based HFS training to produce the most impactful participant experience and improvements 
4. The TEAM instrument is a promising assessment tool for evaluating HFS and teamwork in simulated and clinical environments.
5. Simulation serves a critical role supporting HCD in developing and assessing clinical support tools and integrating AI into the healthcare system.
6. Utilize SbHDT or SbCST to identify LST  Prioritize LST mitigation through the use of FMEA. Evaluate countermeasure implementation and effectiveness through systems integration simulations.

Enhancing Healthcare Team Outcomes

After completing simulation-based, inter-professional training sessions through the Training In Non-technical Skills to Enhance Levels of Medicines Safety (TINSELS) program, study participants attended focus groups to capture the "richness of the human experience" and explore the concepts of non-technical skill acquisition and "safety" development.  For effective intergroup communication to develop, "intergroup anxiety" needed to be managed – a task not adequately addressed within homogeneous professional groups. Investigators accomplished this goal by developing a cooperative goal structure, institutional/normative support for these interactions, and the complexity of "scripts." Researchers highlight the simulated environment as a means to support the pedagogical approach of "exposure-based" inter-professional team training.[62]

Leadership can support establishing "a culture of habitual excellence" through briefings and debriefings to demonstrate transparency and the sharing of problems. Thoughtful crafting and/or facilitation of the debriefing process is demonstrated by the ability to establish the following essential elements: psychological safety, debriefing stance/basic assumption, debriefing rules, and a shared mental model. In a meta-analysis of factors moderating the efficiency and effectiveness of debriefing, researchers revealed that a general discussion of overall performance is enhanced when reflecting on specific past events coupled with cue-strategy associations. This intentional approach to debriefing allows participants to examine actions and their underlying cognitions more deeply. Periods of silence provide for active listening and support transitions between complex topics. This approach also provides an opportunity for facilitators to evaluate non-verbal communication and determine if participants are "ready to learn."[63]

Through the simulation design process, contextual factors are augmented to optimize workflow representation, thus promoting the natural execution of tasks.[64] Participant motivation and engagement are fueled by the "gamification" inherent in the simulation delivery process, thus promoting teamwork and communication skills development.[38] Functional task alignment can be confirmed by measuring participants' immersion in the simulation session.[65] The collection of performance metrics at the team level helps to support methodological alignment when evaluating critical teamwork processes.[66] As previously noted, the incorporation of global rating or behavioral assessment tools into the debriefing session allows for discussion of roles and expectations of the team as a whole.[67] Finally, by asking open-ended questions and confirming that learning objectives have been addressed, this critical component of successful healthcare simulation delivery optimizes the reflective experience of the participants.[68] By enabling teams and individuals to experience the appropriate conceptual, emotional, and physical fidelity of high-risk situations without the potential for patient injury, high fidelity simulation is well suited to assessing HFE through crisis resource management.[47]