Columns, Training

Improving Patient Safety with Simulation: Behavioral Health Emergencies, Appropriate Stretcher Use, Reducing Medication Errors and Pediatric Patients

Issue 2 and Volume 43.

In the December column, three of the 10 topics identified as patient and provider safety issues by the Center for Patient Safety’s EMS Forward initiative1 were discussed and simple objectives with associated simulation activities were provided to help you understand how simulation can support patient safety.

This month we continue the discussion by addressing four additional topics and explore how simulation can support addressing each, thus working to improve patient and provider safety and outcomes.

Behavioral Health

Although behavioral health emergencies serve as a small percentage of overall EMS patient interactions, emergency care providers influence patient outcomes; therefore, behavioral health simulation is important within EMS education.2

All EMS activations involve an emotional response (i.e., stress)—a response providers often become desensitized to, which is one reason that scene safety considerations should be paramount in all simulation scenarios. Behavioral emergencies often come with an unpredictable or heightened emotional response—and with it an increased safety risk.

Many education programs allow learners to verbalize both body substance isolation (BSI) and scene safety at the beginning of a scenario without promoting an actual assessment for safety and assessment of the emotion at the scene. From an educational perspective, simulation activities can be designed to help students understand how to manage patients with behavioral health issues and should require students do more do more than simply verbalize “BSI/scene safety.”

To do this effectively, educators should consider using standardized patients (SPs) as the medium to deliver the activity, as well as standardized embedded participants (SEPs) to set up the environment and provide a realistic immersive experience for students.

SPs are live individuals—often called “actors”—who play the role of a patient. They’re trained to exhibit specific and consistent behaviors and provide responses based on provider activities.3 SPs can be trained to mimic a variety of behavioral health presentations, and to respond positively or negatively depending on whether students choose appropriate ways to de-escalate and engage patients with these conditions.

Similarly, SEPs are live individuals who play the role of someone other than the patient: family members, law enforcement, or anyone else who might influence the way a student handles a particular scenario. SEPs require the same preparation and level of consistency as an SP, and are helpful to guide the scenario or provide clues that could be key to better managing or treating the patient.

Behavioral emergency simulation activities can also be valuable in teaching EMS providers important interprofessional communication skills. Common scenarios include a patient with excited delirium and/or an uncooperative patient with police involvement. Consider a patient who’s placed prone with 2–4 police officers on their back—a high risk for asphyxiation. EMS providers have a medical lens toward patient safety, whereas police officers have a legal focus toward the public’s safety. This type of interprofessional scenario can help EMS providers speak up and confront police officers to advocate for the patient’s safety.

Stretcher Use

It might seem obvious to state that the improper use of stretchers risks harm to patients, but the appropriate use of stretchers is often overlooked during simulation activities, and rarely do they specifically focus on their use.

From novice EMT students who need to be taught these activities to experienced EMS providers who need to be reminded of the importance of proper stretcher use, it’s simple to build this into the objectives and assessment in simulation activities.

For example, do your assessment activities include the proper use of all straps? Do they include ensuring appropriate and complete communication for all stretcher use and movement? Is all of the equipment properly secured and able to withstand an ambulance impact?

Medication Errors

Medication errors can contribute to patient harm or even death and simulation activities can support reducing or eliminating medication mistakes in at least two ways: 1) To identify where errors occur; and 2) To develop and reinforce safe and appropriate medication administration behaviors.

Low-level use of task trainers is an excellent way to teach early learners the basics on appropriate drug administration principles using the six rights of medication administration. However, it’s not until medication administration is embedded in high-fidelity simulation activities involving the full care of a patient in complex situations that we can have the ability to identify what occurs under higher cognitive loads. These complex activities must be run in real-time and in their entirety to ensure accuracy in medication administration.

Pediatric Patients

The design and delivery of simulation activities is essentially the same for pediatric patients as it is for adults, with the differences being in presenting pediatric-specific care elements. Our activity designs of patient progression must mimic real-life evolution of vital signs and other symptoms.

This can be difficult for activities using SPs. There are legal considerations and risks when using children in a medical simulation environment, and children can be difficult to train to behave to the level of standardization required.

Simulation can still be used to support high-quality pediatric care. Do the participants use appropriate pediatric resources and demonstrate changes in thinking? Use of memory aid devices promotes safety and should be used in simulation activities involving pediatric age patients.4 Your assessments of performance should include pediatric-specific elements to ensure closing the age gap in patient care.


Next month we’ll address the final three patient safety topics, each related to a common foundation of professional behaviors.


1. EMS Forward. (2016.) Center for Patient Safety. Retrieved Dec. 27, 2017,

2. Zun L. Care of psychiatric patients: The challenge to emergency physicians. West J Emerg Med. 2016;17(2):173–176.

3. Owens T, Gliva-McConvey G. (2015): Standardized patients. In Palaganas J, Maxworthy J, Epps C, et al. (Eds.), Defining excellence in simulation programs. Lippincott Williams & Wilkins: Baltimore, pp. 199–212, 2015.

4. Barata IA, Benjaimin LS, Mace SE, et al. Pediatric patient safety in the prehospital/emergency department setting. Pediatr Emerg Care. 2007;23(6):412–418.