HiQuiPs: Sim to Win

In HiQuiPs by Jamie RiggsLeave a Comment

It’s a night shift, quieter than usual, though you wouldn’t say so out loud. As if the thought is enough to tempt fate, EMS rolls by. You got no patch, no heads up. “Car accident, just outside the hospital,” a paramedic calls as the patient is transferred onto the trauma stretcher. All you hear are unintelligible moans. All you see is blood streaming from a severely injured face. But the team’s already working, placing IVs, infusing fluids, calling for airway equipment. You’re handed a laryngoscope, but one look tells you all you need to know. You’re not intubating from above, not this time. You call for surgical airway equipment and see a nurse run from the room for a scalpel, but you know what the stock room looks like…

It’s designed to make a stock-keeper’s job easier, not to save a life in a crisis. Image from https://www.pinterest.ca/pin/225109681353313875/

Latent Safety Threats (LSTs)

Resuscitations, with their high stress and even higher stakes, are already vulnerable to errors. Being prepared for any of the injuries that trauma patients can suffer makes these situations especially prone to latent safety threats (LSTs).​1,2​ Like ‘snakes in the grass,’ LSTs are system-based issues that present themselves when the right circumstances manifest, lying in wait until the perfect time to strike.​1,2​ In the case of a critically ill patient, these LSTs too often appear at the most inopportune moments.

Physicians are taught to move to a surgical airway quickly when a top-down intubation won’t be successful, but there are other factors at play that cause delays and ultimately impact care. Where is the scalpel kept? Is a bougie accessible? Can the physical space accommodate the patient and the numerous providers needed to perform procedures? The last thing you want when a critically ill patient is before you is to find out that the equipment you need is down the hall.  

Planning to mitigate these LSTs is one thing, but simulation can take that preparation to a whole new level. To do this, the TRUST study investigators used a new method: ‘stress testing’ the trauma system.​3​

In-Situ Stress Testing

By testing trauma systems in situ (that is, in the place they occur, with the people who normally participate), investigators were able to see how the team truly interacted with their environment during a crisis. Augmenting simulations with audiovisual recording allows leaders to identify inefficiencies that are often overlooked in the live event.

In this case, two critical concerns were identified: (1) delays in blood product administration and (2) delayed set-up for surgical airway procedures.

Going Beyond Expertise and Knowledge

Using in-situ stress testing is important because it allows the team to identify limitations associated with team function and environment, even when every individual member’s expertise and knowledge is substantial. Examples of LSTs that this process can highlight are:

  • communication between team members,
  • challenges in the clinical environment,
  • lack of accessible equipment, and
  • interactions between multiple factors.

Solutions to these problems are often simple to implement, but can save valuable minutes when caring for a trauma patient. After determining that the equipment had previously been held in four different areas of the trauma bay, the TRUST team developed a ‘cric kit’ to facilitate the rapid performance of surgical airways.​3​ Both time and staff were previously needed to secure these pieces of equipment, robbing the patient of necessary resources, but the simple solution of having all the equipment in one easy-to-find kit streamlined the process. Another benefit of these simple solutions is reducing cognitive load on clinicians (editor’s note: more on this coming soon). If finding car keys when you’re running late gives you palpitations, imagine searching for the equipment to perform a cricothyrotomy with a patient’s O2 sat dropping quickly!

It’s Not You, It’s The LSTs

A final benefit of recording these simulations is the ability to shift the focus from individual blame to team processes. For example,  in post-simulation debriefs, participants often described team shortcomings produced by themselves or others on the team.​4​ But with the expert analysis available through video review, it was possible to reorient the conversations from failures of personal competency to an emphasis on LSTs that even the team members themselves did not identify. For example, vital signs monitors were often placed out of the sightline of individuals trying to intubate, a LST that went unnoticed by those involved in the simulations. Because healthcare providers are so often used to finding clever ways to navigate poorly designed spaces and are taught to accept environmental barriers as part of the work, they can often be blind to these safety threats, even when faced with them daily. In a way, a form of ‘learned helplessness’ is developed when healthcare teams constantly adjust to suboptimal system designs, and the objectivity of simulation can bridge this gap by locating those stress points.

It is important to recognize that LSTs faced by one organization will not be universal, but simulation, especially done in situ, can be a powerful tool to identify threats to patients in any environment. In fact, clear debriefing and review of video recordings can provide the critical eye necessary to improve patient care and prevent potentially fatal missteps.


The scalpel arrives just as someone cries, “Time!” The simulation is over, and while the dummy before you lies covered in discarded medical packages and fake blood, thankfully no one was harmed. Through careful review of the case and response, you and your team come up with a slew of recommendations for how it can be done better next time. You can rest easy knowing that next time a difficult airway comes in, that cric-kit you helped develop could save a life.

Want to read more about the TRUST study? More FOAMed here:


  1. 1.
    Alfredsdottir H, Bjornsdottir K. Nursing and patient safety in the operating room. J Adv Nurs. 2008;61(1):29-37. doi:10.1111/j.1365-2648.2007.04462.x
  2. 2.
    Patterson M, Geis G, Falcone R, LeMaster T, Wears R. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013;22(6):468-477. doi:10.1136/bmjqs-2012-000942
  3. 3.
    Petrosoniak A, Fan M, Hicks C, et al. Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review. BMJ Qual Saf. Published online October 23, 2020. doi:10.1136/bmjqs-2020-011363
  4. 4.
    Shah S, McGowan M, Petrosoniak A. Latent safety threat identification during in situ simulation debriefing: a qualitative analysis. BMJSTEL. Published online 2020.

This post was copyedited by Alex Pasqual (Junior Editor) and Matthew Hacker Teper (Senior Editor).

Jamie Riggs

Jamie is an emergency medicine resident at the University of Toronto. He is interested in trauma, medical education and prehospital medicine. Outside of the hospital find him on his bike or hunting for sushi and coffee.

Matthew Hacker Teper

Matthew is a 2nd-year medical student at the University of Toronto, with a strong interest in quality improvement, health systems reform, and emergency medicine. He holds a bachelor’s degree in French Literature and an MSc in Family Medicine. Outside of academia, he is a Special Olympics coach and a triathlete. He is also a part-time culinary student at George Brown College in Toronto.

Andrew Petrosoniak

Emergency Physician & Trauma Team Leader. St Michael's Hospital, Toronto, Canada. Interested in both simulation & social media. #FOAMed supporter.
Chris Hicks

Chris Hicks

Dr. Christopher Hicks is an emergency physician and trauma team leader at St. Michael’s Hospital in Toronto. He is an Education Research Scientist at the Li Ka Shing Knowledge Institute.