Testing the system without breaking it: the risks of in situ simulation

Simulation-based education (SBE) is often justified by its promise to support patient safety. ‘Practise without risk’ is claimed—rehearsing procedures, communication, teamwork and rare high-consequence events without exposing real patients to harm. But ‘practice without risk’ is not absolute. Simulation might cause harm. Learners can be exposed to sharps, defibrillators, gases, fluids, electricity, equipment and unfamiliar environments. Simulation encourages learners to ‘have a go’ and to practise using equipment, tools and techniques that they may not have mastered yet, raising risk. In situ simulation (ISS)—conducted in the real clinical environment—can further magnify risk. Fake drugs can enter real clinical spaces. Simulation equipment can contaminate clinical workflows. Staff can be pulled away from actual patients. So perhaps our risk-benefit analysis of SBE—and especially ISS—needs to be more granular?