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Robot-assisted laparoscopic surgery has gained popularity, which has contributed to a decrease in the number of open procedures. Hence a growing concern regarding the ability of laparoscopically trained surgeons to perform open surgery (e.g. due to bleeding complications) has been raised. The aim of the study was to investigate the ability of conversion to open surgery following exclusively robotic or laparoscopic training. Thirty-six medical students were randomized into three groups: Open surgery, laparoscopy, and robot-assisted laparoscopy. All underwent intensive simulation training in the allocated surgical modality. Subsequently, all study subjects performed an open bowel anastomosis in a pig model where anastomoses were tested for resistance to pressure and leak as a surrogate marker of surgical quality. The primary endpoint was the surgical quality of an open surgery model assessed as, leak pressure, which was 80.01 ± 36.16 mmHg in the laparoscopic training group, 106.57 ± 23.03 mmHg in the robotic training group, and 133.65 ± 18.32 mmHg in the open surgery training group (mean, SD). We found that there were no significant differences between the open surgery training group and the robotic training group whereas a significant difference was found when comparing laparoscopic and open surgery training groups in favor of open procedure training (p < 0.001). In a surrogate open surgery model based on bowel anastomosis, we found that skills acquired through practice on robotic simulation platforms were not significantly worse when compared to skills acquired through training in open surgery, whereas skills acquired from laparoscopic training were significantly poorer when compared to open surgery practice. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about the optimal simulation-based team training in obstetric emergencies. We aimed to review how simulation-based team training affects patient outcomes in obstetric emergencies.Material and Methods: Search Strategy: MEDLINE, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were searched up to and including May 15, 2021.Selection Criteria: randomized controlled trials (RCTs) and cohort studies on obstetric teams in high-resource settings comparing the effect of simulation-based obstetric emergency team training with no training on the risk of Apgar scores less than 7 at 5 min, neonatal hypoxic ischemic encephalopathy, severe postpartum hemorrhage, blood transfusion of four or more units, and delay of emergency cesarean section by more than 30 min.Data Collection and Analysis: The included studies were assessed using PRISMA, EPCO, and GRADE.Results: We found 21 studies, four RCTs and 17 cohort studies, evaluating patient outcomes after obstetric team training compared with no training. Annual obstetric emergency team training may reduce brachial plexus injury (six cohort studies: odds ratio [OR] 0.47, 95% CI 0.33-0.68; one RCT: OR 1.30, 95 CI% 0.39-4.33, low certainty evidence) and suggest a positive effect; but it was not significant on Apgar score below 7 at 5 min (three cohort studies: OR 0.77, 95% CI 0.51-1.19; two RCT: OR 0.87, 95% CI 0.72-1.05, moderate certainty evidence). The effect was unclear for hypoxic ischemic encephalopathy, umbilical prolapse, decision to birth interval in emergency cesarean section, and for severe postpartum hemorrhage. Studies with in situ multi-professional simulation-based training demonstrated the best effect.Conclusions: Emerging evidence suggests an effect of obstetric team training on obstetric outcomes, but conflicting results call for controlled trials targeted to identify the optimal methodology for effective team training. [ABSTRACT FROM AUTHOR]

Objective: To explore the impact of in situ simulation training in regard to identification of latent safety threats and participant experiences.Design: A prospective study including quantitative and qualitative measures.Setting: A Danish hospital shifted from simulation training in centers outside the hospital to training where simulation was conducted where the situations normally took place and with the normal working teams.Participants: A total of 58 local instructors were educated and subsequently conducted in situ simulations in own departments. After each simulation, a log file was completed containing information on location, the scenario, who took part, time, learning points and findings. Furthermore, interviews were conducted with leaders, instructors and simulation participants.Main Outcome Measures: Identified latent safety threats and participant experiences.Results: From June 2017 until December 2018, 323 simulations were conducted representing 35 different wards. They consisted of 40 different scenarios and had both technical and non-technical learning goals. A total of 35 organizational issues were uncovered via the in situ simulation and practice was adjusted accordingly. A total of 11 interviews were conducted. Four themes emerged from the analysis: practice-orientation, endorsement, sense of security and additional impact.Conclusion: Transferring simulation to in situ training resulted in a substantial number of organizational findings. The subsequent follow-up and changes in practice made awareness of what could be latent safety threats. Leaders, instructors and simulation participants experienced in situ simulation as relevant and profitable. [ABSTRACT FROM AUTHOR]

Background and purpose — Virtual reality simulation of hip fracture surgery is available for orthopedic residents nationwide in Denmark. Summative assessment of learning applying the learning curve cumulative summation test (LC-CUSUM) has not been utilized in orthopedic simulation training. The strength of the LC-CUSUM is that it assumes incompetency and signals competency based on solid statistics. We investigated the LC-CUSUM characteristics of novices stepwise mastering the simulated dynamic hip screw (DHS) procedure. Material and methods — 32 1st-year orthopedic residents participated in HipSim and its 3 subsequent LC-CUSUM evaluations: placing a Kirschner wire, placing a Kirschner wire in different patients, and performing the entire DHS procedure in different patients. The career status of the participants, i.e., still working in orthopedics or in another specialty was recorded ≥ 2 years after participation and associated with the simulation performance (passed/failed). Results — 13/14 participants passing HipSim according to LC-CUSUM were still working in orthopedics, while 9/18 participants failing HipSim had quit orthopedics at ≥ 2 years follow-up. The simulator-generated feedback did not statistically significantly differ between the groups. Interpretation — LC-CUSUM and its summative pass/fail assessment of each simulation was feasible in this formative simulation program. Clinical educators can be reassured that participants passing HipSim are likely to continue to 2nd–5th year of residency, while failing HipSim should raise concerns and trigger career counselling and clinical supervision. The motivational aspect of LC-CUSUM pass/fail assessment when designing formative simulation training warrants further research. [ABSTRACT FROM AUTHOR]

It has been consistently documented that the treatment of acute pain is inadequate. Education of medical students is an obvious strategy to improve this. We therefore conducted a study in which 217 medical students were randomized into one of three groups: a control group (no intervention) and two intervention groups (education with e-learning alone or e-learning combined with simulation-based training). We hypothesized that the combined intervention would be superior to no intervention and e-learning alone. All students completed the same multiple choice questionnaire twice with an interval of approximately 1 week. During this 1-week interval, students in the two intervention groups completed either an 45-min interactive case-based e-learning program, or the e-learning program and a simulation-based training. We showed that the theoretical knowledge about treatment of acute pain increased in both intervention groups but students who received the combined intervention felt more confident in the future handling of patients. [ABSTRACT FROM AUTHOR]

Background: Anaesthesiologists are expected to master an increasing number of technical procedures. Simulation-based procedural training can supplement and, in some areas, replace the classical apprenticeship approach during patient care. However, simulation-based training is very resource-intensive and must be prioritised and optimised. Developing a curriculum for simulation-based procedural training should follow a systematic approach, eg the Six-Step Approach developed by Kern. The aim of this study was to conduct a national general needs assessment to identify and prioritise technical procedures for simulation-based training in anaesthesiology.Methods: A three-round Delphi process was completed with anaesthesiology key opinion leaders. In the first round, the participants suggested technical procedures relevant to simulation-based training. In the second round, a needs assessment formula was used to explore the procedures and produce a preliminary prioritised list. In the third round, participants evaluated the preliminary list by eliminating and re-prioritising the procedures.Results: All teaching departments in Denmark were represented with high response rates in all three rounds: 79%, 77%, and 75%, respectively. The Delphi process produced a prioritised list of 30 procedure groups suitable for simulation-based training from the initial 138 suggestions. Top-5 on the final list was cardiopulmonary resuscitation, direct- and video laryngoscopy, defibrillation, emergency cricothyrotomy, and fibreoptic intubation. The needs assessment formula predicted the final prioritisation to a great extent.Conclusion: The Delphi process produced a prioritised list of 30 procedure groups that could serve as a guide in future curriculum development for the simulation-based training of technical procedures in anaesthesiology. [ABSTRACT FROM AUTHOR]

Objectives: New training methods such as simulation have been introduced in cardiology as in other specialties; however, the development of effective simulation-based training programs is challenging. They are often unstructured and based on convenience or coincidence. The objective of this study was to perform a nationwide general needs assessment to identify and prioritize technical procedures that should be included in a simulation-based curriculum for cardiology residency in Denmark.Design: We completed a needs assessment using the Delphi method among key opinion leaders in cardiology. Brainstorming in round 1 identified technical procedures that future cardiologists should learn. Round 2 was a survey to examine frequency of procedure, number of cardiologists performing the procedure, operator-related risk and/or discomfort for patients and feasibility for simulation. Round 3 was final elimination and prioritization of procedures.Results: Ninety-four key opinion leaders were included, and the response rates were 77% (round 1), 62% (Round 2), and 68% (Round 3). Twenty-four technical procedures were identified in Round 1 and pre-prioritized in Round 2. In round 3, 13 procedures were included in the final prioritized list. The five highly prioritized procedures eligible for simulation-based training were advanced life support, pleurocentesis, transesophageal echocardiography, coronary angiography, and pericardiocentesis.Conclusion: The general needs assessment following the Delphi process identified and prioritized 13 technical procedures in cardiology that should be integrated in a simulation-based curriculum. The final list provides educators a guide when developing simulation-based training programmes for cardiology residents. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The number of available simulation‐based models for technical skills training in ophthalmology is rapidly increasing, and development of training programmes around these procedures should follow a structured approach. The aim of this study was to identify all technical procedures that should be integrated in a simulation‐based curriculum in ophthalmology. Methods: Key opinion leaders involved in the education of ophthalmologists in Denmark including heads of departments, heads of clinical education, professors and board members of the society were invited to participate in a three‐round Delphi process. Round 1 aimed at identifying technical procedures that physicians should be able to perform competently when completing specialty training; round 2 involved characterization of each procedure including frequency, number of operators, risk and/or discomfort for patients associated with an inexperienced physician, and feasibility of simulation‐based training; round 3 included a priority ranking of procedures. Results: The response rate for each round was 71%, 64% and 64%, respectively. Sixty‐five procedures were reduced to 25 prioritized procedures during the three rounds. Two‐thirds of the procedures that were identified and highly prioritized were therapeutic procedures such as intravitreal injection therapy, yttrium–aluminium–garnet laser iridotomy/capsulotomy, minor ocular surface procedures and retinal argon laser therapy. The diagnostic procedures that were prioritized were ocular ultrasound, superficial keratectomy and optical coherence tomography (OCT). Conclusion: The Delphi process identified and prioritized 25 procedures that should be practised in a simulation‐based environment to achieve competency before working with patients. The list may be used to guide the development of future training programmes for ophthalmologists. [ABSTRACT FROM AUTHOR]

Objective:Simulation-based training is well recognized in the transforming field of urological surgery; however, integration into the curriculum is often unstructured. Development of simulation-based curricula should follow a stepwise approach starting with a needs assessment. This study aimed to identify technical procedures in urology that should be included in a simulation-based curriculum for residency training. Materials and methods:A national needs assessment was performed using the Delphi method involving 56 experts with significant roles in the education of urologists. Round 1 identified technical procedures that newly qualified urologists should perform. Round 2 included a survey using an established needs assessment formula to explore: the frequency of procedures; the number of physicians who should be able to perform the procedure; the risk and/or discomfort to patients when a procedure is performed by an inexperienced physician; and the feasibility of simulation training. Round 3 involved elimination and reranking of procedures according to priority. Results:The response rates for the three Delphi rounds were 70%, 55% and 67%, respectively. The 34 procedures identified in Round 1 were reduced to a final prioritized list of 18 technical procedures for simulation-based training. The five procedures that reached the highest prioritization were cystoscopy, transrectal ultrasound-guided biopsy of the prostate, placement of ureteral stent, insertion of urethral and suprapubic catheter, and transurethral resection of the bladder. Conclusion:The prioritized list of technical procedures in urology that were identified as highly suitable for simulation can be used as an aid in the planning and development of simulation-based training programs. [ABSTRACT FROM AUTHOR]

Background: Simulation training is a revolutionary addition to health care education. However, developing simulationbased training programs is often dictated by those simulators that are commercially available. Curriculum development requires deliberate planning and a standardized approach, including a 'general needs assessment'. Objectives: The aim of this study was to perform a national general needs assessment to identify technical procedures in pulmonary medicine that should be integrated in a simulationbased curriculum. Methods: A three-round Delphi process was initiated among 62 key opinion leaders. Round 1 was an open-ended question to identify technical procedures pulmonologists should learn. Round 2 was a survey using a newly developed needs assessment formula to explore the fre-quency of procedures, number of operators, risk or discomfort when performed by an inexperienced doctor, and feasibility of simulation-based training. In round 3, results were reviewed and ranked according to priority. Results: The response rates for the three rounds were 74, 63, and 60%, respectively. The Delphi process reduced the 30 procedures identified in round 1 to 11 prioritized technical procedures in round 3. These were: flexible bronchoscopy, pleurocentesis, endobronchial ultrasound, endoscopic ultrasoundguided fine-needle aspiration, noninvasive ventilation treatment, transthoracic biopsy of pleural or lung tumor, focused ultrasound scanning of the lungs, chest tube insertion, needle biopsy of visible lymph node/tumor of the skin, focused ultrasound scanning of the heart, and thoracoscopy. Conclusion: We performed a Delphi study using a needs assessment formula, which identified 11 technical procedures that are highly suitable for simulation-based training. Medical educators can use this list as a resource in planning simulation- based training programs for trainees in pulmonary medicine. [ABSTRACT FROM AUTHOR]

This insider action research project aimed to improve interprofessional team performance at a surgical ward. The purpose of the project was (1) to critically appraise potential deficiencies in staffs’ identification, clinical judgment, and management of deteriorating ward patients, (2) to develop an interprofessional change model, and (3) evaluate the impact of the change model and the AR process. The insider AR project took place at a large Danish surgical ward with 60 participating physicians and nurses. The study was conducted in three interconnected action and reflection cycles using mixed methods. Staff viewed the co-creation and co-inquiry as important resources in transforming the ward into a better microsystem. Microsystems as a theoretical framework was used to conceive the success of health system redesign as a matter of enabling the clinical team to meet patient needs. By combining insider AR with microsystems, this study highlights the importance of senior leaders to recognize the nature and power of using the microsystem approach for strategy, excellence, innovation, and research. Staff was able to formulate an overarching vision of interprofessionalism and this helped inspire changes in clinical practice for the benefit of our patients. [ABSTRACT FROM AUTHOR]

The article discusses an observational simulation-based study of interprofessional team communication. The researchers aimed to develop a theory-based evaluation instrument that measures and qualifies team communication as well as investigate the quality and content of summaries and re-evaluations that evolve step wise and progressively in the treatment of critically ill patients. The study found that complex interprofessional team communication does not readily simplify to mere observation.

Background: A growing body of evidence supports the existence of an association between patient safety culture (PSC) and patient outcomes. PSC refers to shared perceptions and attitudes towards norms, policies and procedures related to patient safety. Existing literature shows that PSC varies among health professionals depending on their specific profession and specialty. However, these studies did not investigate whether PSC can be improved. This study investigates whether length of education is associated with improvements in PCS following a simulation intervention., Methods: From April 2017 to November 2018, a cross-sectional intervention study was conducted at two regional hospitals in Denmark. Two groups with altogether 1230 health professionals were invited to participate. One group included nurses, midwives and radiographers; the other group included doctors. A train-the-trainer intervention approach was applied consisting of a 4-day simulation instructor course that emphasised team training, communication and leadership. Fifty-three healthcare professionals were trained as instructors. After the course, instructors performed in situ simulation in their own hospital environment., Outcomes: The Safety Attitude Questionnaire (SAQ), which has 6 dimensions and 32 items, was used to collect main outcome variables. All employees from both groups were surveyed before the intervention and again four and nine months after the intervention., Results: Mean baseline scores were higher among doctors than among nurses, midwives and radiographers for all SAQ dimensions. At the second follow-up, four of six dimensions improved significantly (p ≤ 0.05) among nurses, midwives and radiographers, whereas no dimensions improved significantly among doctors., Conclusion: Over time, nurses, midwives and radiographers improved more in PSC attitudes than doctors did., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This article was migrated. The article was marked as recommended., Objective: This study introduced a lens of liminal theory, drawn from anthropological classical ritual theory, to explore how a preparatory teaching format using video casesinfluenced medical students' patient approaches in their subsequent psychiatric clerkship. The video cases portrayed simulated patient-doctor encounters in diagnostic interview situations and were hypothesized to function as a liminal trickster., Methods: The study applied a qualitative explorative design using individual rich picture interviews. We asked the students to draw their experiences, which we investigated using a semi-structured interview guide designed to capture and unfold the students' perspectives. We explored how students navigated insights from the preparatory teaching in their clerkship using liminal theory concepts in a mixed inductive and deductive thematic analysis., Results: The results from 8 rich picture interviews demonstrated that students' ability to navigate insight gained from the video cases in their clerkship varied according to their roles in the clinical diagnostic interview situations. Students having active roles in the diagnostic interview situation adopted a patient-centred focus demonstrating empathic engagement and self-reflexivity related to their learning experiences with the video cases. Students with passive roles described a focus on how to adopt an appropriate appearance and copied the behaviour of the simulated doctors in the video cases., Conclusion: The liminal ritual theory perspective to explore the influence of preparatory teaching was useful for demonstrating how video cases could affect students' patient-centred learning. Without guidance and active roles in clerkship, medical students' learning experiences may lead to a prolonged liminal phase and may not capitalise on the potentially positive effects of the preparatory teaching. Liminal theory may further inform our understanding of students' learning considering patient cases in educational technology arrangements as tricksters., (Copyright: © 2021 Pedersen K et al.)

Context: Several neonatal simulation-training programs have been deployed during the last decade, and in a growing number of studies, researchers have investigated the effects of simulation-based team training. This body of evidence remains to be compiled., Objective: We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome., Data Sources: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library., Study Selection: Two authors included studies of team training in critical neonatal situations with reported outcomes on clinical performance and patient outcome., Data Extraction: Two authors extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool 2.0 and the Newcastle-Ottawa quality assessment scale., Results: We screened 1434 titles and abstracts, evaluated 173 full texts for eligibility, and included 24 studies. We identified only 2 studies with neonatal mortality outcomes, and no conclusion could be reached regarding the effects of simulation training in developed countries. Considering clinical performance, randomized studies revealed improved team performance in simulated re-evaluations 3 to 6 months after the intervention., Limitations: Meta-analysis was impossible because of heterogenous interventions and outcomes. Kirkpatrick's model for evaluating training programs provided the framework for a narrative synthesis. Most included studies had significant methodologic limitations., Conclusions: Simulation-based team training in neonatal resuscitation improves team performance and technical performance in simulation-based evaluations 3 to 6 months later. The current evidence was insufficient to conclude on neonatal mortality after simulation-based team training because no studies were available from developed countries. In future work, researchers should include patient outcomes or clinical proxies of treatment quality whenever possible., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: This study aimed to investigate staff's perceptions of patient safety culture (PSC) in two Danish hospitals before and after an in situ simulation intervention., Design: A repeated cross-sectional intervention study., Setting: Two Danish hospitals. Hospital 1 performs emergency functions, whereas hospital 2 performs elective functions., Participants: A total of 967 healthcare professionals were invited to participate in this study. 516 were employed in hospital 1 and 451 in hospital 2. Of these, 39 were trained as simulation instructors., Intervention: A 4-day simulation instructor course was applied. Emphasis was put on team training, communication and leadership. After the course, instructors performed simulation in the hospital environment. No systematic simulation was performed prior to the intervention., Main Outcome Measures: The Safety Attitude Questionnaire investigating PSC was applied prior to the intervention and again 4 and 8 weeks after intervention. The proportion of participants with a positive attitude and mean scale scores were measured as main outcomes., Results: The response rate varied from 63.6% to 72.0% across surveys and hospitals. Baseline scores were generally lower for hospital 1. The proportion of staff with positive attitudes in hospital 1 improved by ≥5% in five of six safety culture dimensions, whereas only two dimensions improved by ≥5% in hospital 2. The mean scale scores improved significantly in five of six safety culture dimensions in hospital 1, while only one dimension improved significantly in hospital 2., Conclusions: Safety attitude outcomes indicate an improvement in PSC from before to after the in situ simulation intervention period. However, it is possible that an effect is more profound in an acute care hospital versus an elective setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To identify and prioritise technical procedures that should be integrated in a curriculum of simulation-based procedural training in paediatrics using the Delphi method., Study Design: National general needs assessment using a Delphi process was completed among 93 key opinion leaders in paediatrics in Denmark. Delphi round 1 identified technical procedures. Round 2 explored frequency of procedures, number of paediatricians performing the procedures, risks and/or discomfort for patients and feasibility for simulation-based training. Round 3 included final elimination and reprioritisation., Results: Response rates in the Delphi rounds were 73%, 71% and 72%. We identified 37 procedures in Delphi round 1, preprioritised in round 2, resulting in a final list of 19 procedures in round 3. Strong correlation between the prioritisation from the second and third Delphi rounds was identified, Spearman's r of 0.94 (p<0.0001). Top five on the final list were acute neonatal airway management, acute non-neonatal airway management, non-neonatal peripheral intravenous and intraosseous access, neonatal vascular access and advanced heart lung resuscitation., Conclusion: We identified and prioritised 19 technical procedures in paediatrics that are suitable for simulation and may be used as a guide for the development of simulation-based curriculum in paediatrics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To evaluate the effectiveness of including interactive video-based patient cases in preparatory lectures on medical students' patient-centredness and attitudes towards psychiatry., Methods: This study was designed as a quasi-experimental intervention study. A preparatory lecture on diagnostic interviewing was given to 204 fourth-year medical students before a 4-week psychiatry clerkship. The students were divided into two groups. One group (n=102) received a preparatory lecture including an interactive video case portraying a doctor performing a diagnostic interview with a simulated patient (intervention group). The other group (n=102) received a conventional preparatory lecture using text-based instructional material (control group). We conducted a paired sample t-test to compare the students' confidence in exhibiting patient-centred communication and their attitudes towards psychiatry before receiving the preparatory lecture and after having completed a minimum of three weeks of clerkship training., Results: A total of 102 students, 51 in each group, completed a questionnaire at both measurement points. In the intervention group, we found a statistically significantly difference for the students' patient-centredness before (M=69.4, SD=10.0) and after (M=73.8, SD=8.6) the intervention t (97) =2.38, p= 0.02, but no changes in attitudes t (98) =1.07, p=0.28. In the control group, we found no changes in patient-centredness or attitudes., Conclusions: Video cases in preparatory lectures appear to be better than text-based material at improving students' patient-centredness in psychiatry. However, neither video cases nor text-based material seem to influence the students' attitudes.

Background: This intervention study aimed to enhance patient safety attitudes through the design of an in situ simulation program based on a needs analysis involving thematic analysis of patient safety data and short-term ethnography. The study took place at an Emergency Department (ED) in the Central Region of Denmark. Research suggests that poor handover communication can increase the likelihood of critical incidents and adverse events in the ED. Furthermore, simulation is an effective strategy for training handover communication skills. Research is lacking, however, on how to use patient safety data and a needs analysis to the design of in situ simulation communication training., Methods: This is a prospective pre-post study investigating the interventional effects of in situ simulation. It used a three-pronged strategy: (1) thematic analysis of patient safety data consisting of reported critical incidents and adverse events, (2) a needs analysis based on short-term ethnography in the ED, and (3) pre-post evaluation using the validated Safety Attitudes Questionnaire (SAQ) and the Trainee Reactions Score., Results: Sixteen different healthcare teams participated composed by 9 physicians and 30 nurses. In the SAQ, participating staff scored their safety attitudes in six categories ( n  = 39). Two measures where significantly higher for the post-SAQ than those for the pre-SAQ: teamwork climate ( p  < 0.001) and safety climate ( p  < 0.05). The Trainee Reactions Score showed that the training was positively evaluated., Conclusions: This study designed a feasible strategy for implementing in situ simulation based on a needs analysis of critical incidents and adverse events and short-term ethnography.