Program Fundamentals

Critical actions for effective simulation experiences



Amar P. Patel | Graham E. Snyder, MD | From the Making It Real Issue

Located in Raleigh, N.C., WakeMed Health & Hospitals’ Center for Innovative Learning is one of the leading providers of simulation-based education. It offers more than 50 courses, as well as programs that focus on utilization of simulation technology, effective debriefing, simulation operations and facilitation of human patient simulators.

Why Simulation?
Traditional medical education often falls short when it comes to training students on how to prioritize and multitask. At the bedside or in the field, the student is never truly forced to face the consequences of mis-prioritizing interventions, because the instructor will always intervene to prevent harm to a real patient.

Unique to medical simulation is its ability to teach prioritization and multitasking and, most importantly, demonstrate the consequences of poor decisions.

What makes EMS unique is its uncontrolled, fast-paced environment, which can facilitate poor decision-making, but it also requires mastering skills that aren’t used that often. Mastery of these skills begins with understanding all the processes involved in completing a given task.

Hospital-based simulation studies have shown that, if an instructor can measure an individual’s competency in a particular skill, as well as time-to-task and decision-making, the student may achieve competency more quickly.1–11 And if competency is achieved more quickly, decision-making skills will also improve.

Steps to Simulation
1. Identify the problem. Take an honest inventory of where mistakes happen and where the knowledge gaps are widest in your health-care system.
2. Identify all the players. Whether it’s the 9-1-1 operators or the receiving hospital’s triage process, issues are never isolated. Developing a new simulation program can provide education to your EMS providers, as well as the local hospital and communications center staff, so all the players must be present from the beginning.
3. Develop measurable goals. What is the primary reason for developing a simulation program? Education? Research? Clearly identify the goals before writing the curriculum.
4. Determine the training and simulation technology needed. Whether you’re starting a multi-disciplinary simulation program that provides training for prehospital and hospital personnel, or an air-medical education resource and critical-care transport, purchase the equipment that best fits your program. It will save you hours of work and a tremendous amount of money. Leasing, borrowing and sharing equipment prior to purchase will also save you money.
5. Develop and validate scenarios. How a scenario should perform and how it will actually perform will differ with student involvement. For this reason, it’s critical to practice scenarios with a staff member before students attend the program.
6. Implement the scenarios. To give students the best experience possible, maximize realism and minimize levity. The environment should not be hostile, but it should be as realistic as possible.
7. Collect and analyze data, and conduct a debriefing. Elicit feedback in a positive manner. Then openly discuss the scenario's pre-identified critical actions/goals.
8. Finally, ask your fellow instructors and students: Did you solve the problem?

The key components for effective implementation include identifying the goals/problems, understanding the technology and ensuring it will help you reach your goal, and objectively measuring both the effectiveness of the simulation and the real patient impact long after simulation completion. If you design your simulation program to have all of these components and you implement them properly, your program will be successful and benefit your community for years to come.

Disclosure: Patel has reported receiving honoraria, either directly or indirectly, from the sponsor of this supplement. Snyder has reported no conflicts of interest.

1. Johnson L, Patterson M. Simulation education in emergency medical services for children. Clinical Pediatric Emergency Medicine. 2006;7:121–127.
2. Maran NJ, Glavin RJ. Low- to high-fidelity simulation—A continuum of medical education? Medical Education. 2003;37:22–28.
3. Russell S. An Overview of Adult Learning Processes. Medscape. 547417_2. Accessed June 18, 2010.
4. Wright S, Lindsell C, Hinckley W, et al. High-fidelity medical simulation in the difficult environment of a helicopter: Feasibility, self-efficacy and cost. BMC Medical Education. 2006;6:49.
5. Gordon J, Wilkerson W, Shaffer D, Armstrong E. “Practicing” medicine without risk: Students’ and educators’ responses to high-fidelity patient simulation. Academic Medicine. 2001;76; 469–472.
6. Dunn, WF. Simulators in critical care and beyond. 2004; Society of Critical Care Medicine: Des Plaines, Ill. 
7. Gaba DM, Fish KJ, Howard SK. Crisis Management in Anesthesiology. 1993; Churchill Livingstone: Philadelphia.
8. Loyd GE, Lake CE, Greenberg, RB. Practical Health Care Simulations. 2004; Hanley and Belfus: Philadelphia.
9. Berndt TJ. Friendship quality and social development. Current Directions in Psychological Science. 2002;11:7–10.
10. Ziv AZ, Wolpe PR, Small SD, et al. Simulation-based medical education: An ethical imperative. Academic Medicine. 2003;78:783–788.
11. Biese KJ, Moro-Sutherland D, Furberg RD, et al. Using screen-based simulation to improve performance during pediatric Resuscitation. Academic Emergency Medicine. 2009;16 (12suppl):S71–S75.

This article originally appeared in an editorial supplement to the September 2010 issue of JEMS as “Program Fundamentals: Critical actions for effective simulation experiences.”

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Related Topics: Amar Patel, simulations, EMS training, manikin, mannequin, WakeMed


Amar P. Patelis the manager for WakeMed Health & Hospitals’ Center for Innovative Learning. He has more than 16 years of experience in fire, EMS and critical-care transport as a firefighter, a paramedic and an educator. He has also taught at numerous national simulation conferences and has a passion for improving safety in healthcare.


Graham E. Snyder, MDGraham E. Snyder, MD, is the medical director of the WakeMed Health and Hospitals Medical Simulation Center and the associate program director of the UNC Emergency Medicine Residency. Contact him at


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