Columns, Commentary, Training

Improving Patient Safety with Simulation: Ambulance Safety and Provider Mental Health

Issue 4 and Volume 43.

Simulations supporting ambulance safety & mental health

This month, we wrap up the discussion related to the 10 EMS patient safety topics identified by the Center for Patient Safety,1 and how simulation can be a part of improving safety in your agency. The last two topics are ambulance crashes and provider mental health.

Ambulance Crashes

There’s been increased focus on ambulance crashes lately, including in the recent publication of evidence-based guidelines for fatigue risk management in EMS.2

Simulation activities to raise awareness about behaviors and philosophy that contribute to ambulance safety can take many forms. There are many options to improve specific driving skills through simulation. Driving activities that include maneuvering through a maze of cones, often incorporated as part of driver safety courses, are an excellent opportunity to simulate responses to sudden changes in driving conditions. The driver can learn to react to quickly and safely to these rapidly changing driving conditions.

Much more difficult to simulate are the underlying provider behaviors that contribute to ambulance crashes. Fatigued driving and failure to wear seatbelts are two examples of decisions made by individuals that affect provider and patient safety.

These decisions are often indicative of a culture where staff are ill-informed about the risks of poor driving habits and don’t recognize that it’s important for the providers to be safe in order for them to deliver care to the patients we’re trying to help.

Driving simulators can safely allow participants to command a vehicle in a fatigued state. Simulation activities taking place in the back of the ambulance can help reinforce effective restraint protocols for improved survivability during ambulance crashes

In addition to provider decision-making responsibility, EMS leadership must engage in solutions to reduce fatigue amongst the workforce and advance a patient safety culture.

A patient safety culture goes far beyond these simple examples. CPS defines a patient safety culture as, “The result of an organizational commitment to safety permeating all levels from frontline personnel to executive management. Features of a culture of safety include acknowledgment of the high-risk, error-prone nature of an organization’s activities, a just environment where individuals are able to report errors and near misses without fear of reprimand or punishment, an expectation of collaboration across ranks to seek solutions to vulnerabilities and a willingness on the part of the organization to direct resources for addressing safety concerns.”3

It should be evident on reading that a patient safety culture requires a deliberate, continuous and structured effort on the part of individuals and organizations to achieve. To achieve safety improvement, it’s critical to break down old ways of thinking and behaving.

When a patient safety culture is achieved, wearing seatbelts becomes the standard. Providers won’t think twice as they don gloves while starting an IV, because it’s the best way to protect patients and providers from blood-borne pathogens. Provider fatigue should also be reduced, because an agency with a patient safety culture encourages, supports and requires monitoring the risks.

Provider Mental Health

The last patient safety topic is provider mental health. There’s a growing awareness of the challenges that EMS providers face in mental health. This includes post-traumatic stress disorder and suicide.4 An effective patient safety culture includes the safety of providers.

In simulation, and specifically in debriefing, there’s an opportunity to engage in self-reflection and discuss the feelings surrounding patient care decisions, teamwork and communication. This is essential for maintaining connectedness and authenticity of the team.5

After all, we can’t care for patients if we don’t care for our own. Unfortunately, too often we neglect practicing how to care for each other and focus our attention on practicing caring for our patients. Making provider mental health a priority is essential and can be addressed in debriefing sessions following simulation activities.

Patient Safety Simulation Design

Simulation activities can have a significant impact on creating, developing and maintaining a patient safety culture. They are an effective way to eliminate bad habits and unsafe practices and behaviors.

Table 1 offers a few suggestions and examples of design components that can be used to build simulation activities that can be used to enhance a patient safety culture. Even when patient safety isn’t a primary learning objective of a simulation activity, elements of the activity can still be embedded to support developing and maintaining a patient safety culture.

Simulation activities allow participants to safely make errors, which is very powerful. Certainly, demonstration of correct knowledge, skills and attitudes is desired, but the beauty of a well-designed simulation activity is that it is a safe way where errors and near-errors can be detected and corrected—before a real patient or provider is harmed.

Engaging the concepts of patient safety into each simulation activity, and deliberately engaging in thoughtful self-reflection in the debriefing will lead to fostering a patient safety culture. That’s powerful simulation indeed!


Our challenge to you is to grow and foster a patient safety culture supported and reinforced using simulation activities. Each individual and each agency has a responsibility to do no harm.

A patient safety culture embraces this principle, and we can never forget that it’s a culture that protectsa both patients and providers.


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

2. Patterson PD, Higgins JS, Van Dongen HPA, et al. Evidence-based guidelines for fatigue risk management in emergency medical services. Prehosp Emerg Care. 2018;22(sup1):89–101.

3. Patient safety glossary. (2018.) Center for Patient Safety. Retrieved Feb. 27, 2018, from

4. Martin CE, Tran JK, Buser SJ. Correlates of suicidality in firefighter/EMS personnel. J Affect Disord. 2017;208:177–183.

5. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007;2(2):115–125.