Poster Abstract

In situ Simulation Sessions in the Operating Room: An Unexpected Opportunity to Identify System Errors (P095)

Elaine Ng (Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario); Elizabeth McLeod (Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario); Jane Tipping (Office of CEPD, University of Toronto, Toronto, Ontario); Savithiri Ratnapalan (Department of Emergency Medicine, Hospital for Sick Children, Toronto, ON)


System errors were discovered as a result of in situ simulation in the operating room. Correction of these latent safety threats may enhance patient safety.


In situ simulation allows for practice of crisis resource management in the actual workplace.

Six simulation sessions were conducted in the OR for nurses and anesthesiologists. The computerized mannequin (Simbaby®, by Laerdal) was set up in an OR. Two clinical scenarios of similar complexity were conducted with debriefing after each case. Participants completed a multiple choice evaluation of the session and documented their reflections in a “one minute paper”.

The objective of the study is to identify themes and perceptions of competence and confidence in team function.


Research was approved by local Research Ethics Board to conduct a retrospective qualitative analysis of the evaluations and reflections.


There were 40 participants (30 nurses, 10 anesthesiologists). The themes indicated the need for clear communication, awareness and self reflection of medical knowledge and familiarity with equipment, and importance of task designation and role identification. System issues identified that the location of certain resuscitative medications was not obvious. The crash cart designated for use was not configured the same way as other crash carts in the area. Treatment protocols were not immediately available. The telephone at the main OR desk was found to be on voicemail when help was required.

Conclusions and Discussion

In situ simulation allows practice of resuscitation and crisis resource management skills. In addition, system errors and latent safety threats were identified and have since been corrected which may enhance patient safety.