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In this chapter, we present some key considerations for the design of simulation scenarios and a script that can guide users systematically through the process of scenario design. The main guiding principle for scenario design is seen in the learning goals that participants should reach by working through the scenario. Example scenarios are referenced, which are used for many different areas of health care. The script itself provides a summary page for quick reference, a development part with more space to provide details, and an instruction part that can be separated to provide instructions to the participants and potential role players or simulated patients.

Ein groser Anteil von Zwischenfallen in der Medizin hat seine Ursache im Bereich menschlicher Faktoren. Das Crew Resource Management (CRM-Konzept) hat zum Ziel, die Rate an Komplikationen und Zwischenfallen durch eine Optimierung der menschlichen Zusammenarbeit und Leistung zu reduzieren. Die Notwendigkeit, dies zu tun, ist auch bei Medizinischen Einsatzteams (MET) sehr wichtig. Die weltweit verbreiteten CRM-Leitsatze von Rall & Gaba werden in der Anwendung fur MET erlautert. Um CRM im Team umzusetzen, bieten sich CRM-basierte Simulations-Teamtrainings ebenso an wie spezielle CRM-Seminare. Keine Intervention erhoht zurzeit die Patientensicherheit und Teamzufriedenheit so sehr wie CRM-Teamtrainings. Daher ist CRM-Training ein „Muss“ fur alle MET.

In this chapter, we describe key considerations for the training of simulation educators. Based on the tasks that they are asked to perform, simulation educators need a range of knowledge, skills, and professional attitude. We describe those on a high level, mention models to assess competence, define some of the implications for their training, and provide examples of course programs.

Der technologische Fortschritt der Simulationshersteller hat es in den letzten Jahren zunehmend einfacher gemacht, die realitatsnahe Simulation auch auserhalb von fest aufgebauten Simulationszentren durchzufuhren. Der erste realitatsnahe Simulator »SimOne « aus dem Jahr 1961 hat mehrere Raume gefullt und hatte eine Vielzahl von schweren Computern und Maschinen konnektiert, so dass eine mobile Simulation allein schon aufgrund der Technologie unmoglich gewesen ware (► Kap. 25; [1], [5]). Aber auch die Nachfolgegeneration in den 80er und 90er Jahren waren noch sehr grose Simulatoren, die mit schweren, auserhalb der Patientenpuppe aufgestellten Gerateturmen mit Simulationstechnik verbunden waren, so dass ein Transport dieser Simulatoren nur mit grosem Aufwand und grosen Transportgeraten moglich war. Seit Einfuhrung der kompakten Simulatoren, die anfanglich bis auf die Druckluft und die Computersteuerung im Wesentlichen alle Aggregate innerhalb der Simulationspuppe integriert hatten, war es moglich, die Simulation mit vertretbarem Aufwand mobil anzubieten. Inzwischen werden Simulatoren angeboten, die ganzlich ohne Kabelverbindungen auskommen (Funksteuerung , Druckluft und Flussigkeit im Mannequin gespeichert).

Hintergrund: Die Verbesserung der Patientensicherheit in der Endoskopie ist nicht einfach und nicht von heute auf morgen zu realisieren. Der größte Anteil an schwerwiegenden Zwischenfällen bei der Endoskopie ist auf die Sedierung zurückzuführen. Methode: Anwendung der Inhalte der S3-Leitlinie sowie aktueller Kenntnisse zur Erhöhung der Patientensicherheit. Ergebnisse: Es ist selbstverständlich, dass die gemäß der aktuellen S3-Leitlinie geforderten Personal-, Struktur- und Prozessvoraussetzungen bei einer Sedierung in der Endoskopie auch bei Personalknappheit kompromisslos eingehalten werden. Risikopatienten müssen zuverlässig identifiziert und dann von entsprechend (intensivmedizinisch) erfahrenem Personal während endoskopischer Eingriffe betreut werden. Dennoch gilt: Fehler sind in komplexen Systemen zu erwarten und insofern «normal». Aber wir müssen aus Fehlern lernen. Hierfür bieten moderne softwarebasierte «Critical Incident Reporting»-Systeme (CIRS) gute Voraussetzungen. 70% der medizinischen Fehler beruhen nicht auf mangelndem Fachwissen, sondern auf Problemen im Bereich der Human Factors (HFs). Crisis Resource Management (CRM) ist ein effektives Tool gegen HF-bedingte Fehler und sollte in Zukunft von allen beherrscht werden. Schlussfolgerungen: Der aktuelle Goldstandard für HF/CRM-Training ist der Einsatz von realitätsnahen und modernen Simulationsteamtrainings, die von speziell geschulten Instruktoren durchgeführt werden. Um die Patientensicherheit nachhaltig zu erhöhen, sind die Autoren der Auffassung, dass Simulationstrainings zu Sedierungen und Zwischenfällen in der Endoskopie mindestens zweimal pro Jahr für jeden medizinischen Mitarbeiter bei Sedierungen in der Endoskopie durchgeführt werden sollten.

Introduction:A standardized team-training program for healthcare professionals in obstetric units was developed based on an analysis of common causes for adverse events found in claims registries. The interdisciplinary and inter-professional training concept included both technical and non-technical skill training. Evaluation of the program was carried out in hospitals with respect to the immediate personal learning of participants and also regarding changes in safety culture.Methods:Trainings in n=7 hospitals including n=270 participants was evaluated using questionnaires. These were administered at four points in time to staff from participating obstetric units: (1) 10 days ahead of the training (n=308), (2) on training day before (n=239), (3) right after training (n=248), and (4) 6 months after (n=188) the intervention. Questionnaires included several questions for technical and non-technical skills and the Hospital Survey on Patient Safety (HSOPS).Results:Strong effects were found in the participants’ perception of their own competence regarding technical skills and handling of emergencies. Small effects could be observed in the scales of the HSOPS questionnaire. Most effects differed depending on professional groups and hospitals.Conclusions:Integrated technical and team management training can raise employees’ confidence with complex emergency management skills and processes. Some indications for improvements on the patient safety culture level were detected. Furthermore, differences between professional groups and hospitals were found, indicating the need for more research on contributing factors for patient safety and for the success of crew resource management (CRM) trainings.

Patient Safety is not a side-effect of good patient care by skilled clinicians. Patient safety is a subject on its own, which was traditionally not taught to medical personnel. This must and will dramatically change in the future. The 2010 Helsinki Declaration for Patient Safety in Anaesthesiology states accordingly "Education has a key role to play in improving patient safety, and we fully support the development, dissemination and delivery of patient safety training". Patient safety training is a multidisciplinary topic and enterprise, which requires us to cooperate with safety experts from different fields (e.g. psychologists, educators, human factor experts). Anaesthesiology has been a model for the patient safety movement and its European organisations like ESA and EBA have pioneered the field up to now: Helsinki Patient Safety Declaration and the European Patient Safety Course are the newest establishments. But Anaesthesiology must continue in its efforts in order to stay at the top of the patient safety movement, as many other disciplines gain speed in this topic. We should strive to fulfill the Helsinki Declaration and move even beyond that. As the European Council states: "Education for patient-safety should be introduced at all levels within health-care systems"

We describe how simulation and incident reporting can be used in combination to make the interaction between people, (medical) technology and organisation safer for patients and users. We provide the background rationale for our conceptual ideas and apply the concepts to the analysis of an actual incident report. Simulation can serve as a laboratory to analyse such cases and to create relevant and effective training scenarios based on such analyses. We will describe a methodological framework for analysing simulation scenarios in a way that allows discovering and discussing mismatches between conceptual models of the device design and mental models users hold about the device and its use. We further describe how incident reporting systems can be used as one source of data to conduct the necessary needs analyses - both for training and further needs for closer analysis of specific devices or some of their special features or modes during usability analyses.

Preventing patient harm is one of the main tasks for the field of anesthesiology from early on. With the introduction of the national German incident reporting system PaSOS, which is hosted by the German anesthesia society, anesthesiology is again leading the field of patient safety. Important elements, success factors and background information for the introduction of successful incident reporting systems in an organization are given. Examples by and from PaSOS are given.

Role playing is an important element of virtually all simulation-based procedures. An improved understanding for methodological aspects facilitates its goal-oriented use in education and training, research and examinations. In the present paper we describe how different forms of role play are used in different simulation-based procedures. We describe a plausibility study from skills labs demonstrating that the introduction of role-playing can increase perceived realism. Finally we derive practical suggestions for the conduction of role plays in medical simulation.

Following the framework of ecological validity, and taking into account the social character of simulation, we investigated how six anesthesiologists each experienced three patient simulation scenarios. Using content analysis, we describe factors mentioned in the 18 half-structured interviews that were relevant for the perceived realism of the scenarios: overall impression and medical plausibility, participants' own actions, role play of the simulator team, workload, technical aspects, group dynamics, and anticipations. Further, we describe the circumstances under which these relevant elements were experienced as fiction cues (emphasizing differences between scenarios and clinical cases) or as reality cues (emphasizing similarities between scenarios and clinical cases). The experience of the scenarios among the anesthesiologists was dynamic over time and differed among participants. Considering the described elements and their character as either fiction or reality cues improves the understanding of the still-unanswered question of why simulators and simulations “work.” Simulators and simulations help in designing, optimizing, conducting, and analyzing patient simulation scenarios in a goal-oriented fashion.

This study investigated the behavioural aspects of ecological validity of anaesthesia simulation environments using a task analysis approach. Six anaesthesists were observed during two cases performed in the operating room (OR), one routine and two critical incident simulation scenarios. A two-way MANOVA for repeated measures was performed with the independent variables Case (OR/SIM-R/SIM-CI) and Phase Induction/ Maintenance (Emergence), the latter being a repeated measure. Dependent variables were the proportion of each phase spent on each of the observation categories. Statistically significant main effects for Phase concerning communication, monitoring, manual tasks and documentation, for Case concerning communication and documentation, and a significant interaction effect for Phase x Case concerning manual tasks and other were found. Increased action density (i.e. amount of co-occurring activities) was observed during Induction, Emergence and the Management of simulated critical events. The similarities and differences in anaesthetists' activity patterns identified in this study will help to further improve the ecological validity of simulation environments as research settings.

Der Patient wird nicht richtig behandelt, obwohl das Team eigentlich gewusst hatte, was zu tun ist und es auch gekonnt hatte: Das sind typische Kennzeichen fur ca. 70 % aller Zwischenfalle und unerwunschter Patientenschaden in der Medizin. Ursache sind die „menschlichen Faktoren“ (Human Factors)! Das sogenannte Crew Resource Management (CRM) kann solche Fehler erwiesenermasen deutlich reduzieren. Bis heute werden Human Factors und CRM leider immer noch kaum systematisch gelehrt und trainiert. Die meisten Teams haben somit geringe Kenntnisse uber 70 % der Fehlerursachen. Das muss sich andern und kann sich andern. Dies zeigen die ersten systematischen Projekte, zum Beispiel bei der RKISH: Seit uber vier Jahren werden dort systematisch die 15 CRM-Leitsatze nach Rall und Gaba (2009) in regelmasig stattfindenden Simulationsteamtrainings gelehrt. Die Effekte sind uberzeugend, nicht nur fur die Erhohung der Handlungssicherheit, sondern auch was die Zufriedenheit der Mitarbeiter im Team betrifft.

Eine grose Anzahl von Patientenschaden entsteht durch Fehler. Man geht davon aus, dass „Fehler in der Medizin“ zu den 10 haufigsten Todesursachen zahlen. Andere Industrien haben seit fast 50 Jahren systematisch und mit grosem Erfolg an der Erhohung der Handlungssicherheit ihrer Teams gearbeitet. Diese Industrien werden als Hochzuverlassigkeitsorganisationen bezeichnet (High Reliability Organsiations, HRO). Eine der wichtigsten Grundvoraussetzungen fur HROs ist die Erkenntnis, dass Fehler nicht das Problem von einzelnen sind, und auch nicht die Schuld von wenigen, sondern dass Zwischenfalle ihre Ursachen in zahlreichen Faktoren finden, welche oft schon lange vor dem Unfall vorhanden waren (latente Schwachen im System). Dieser Systemansatz von Sicherheit fuhrt dann zur Notwendigkeit einer positiven, proaktiven Sicherheitskultur, in der Sicherheit die hochste, allgemein anerkannte Prioritat besitzt: „Wir konnen uber alles verhandeln, aber nicht uber die Einschrankung von Sicherheit oder die bewusste Inkaufnahme bekannter Risiken.“

Airway management is a cornerstone of patient safety in anaesthesiology and in emergency and critical care medicine. Deficiencies in airway management could have catastrophic results for the patient. In anaesthesia patients, in particular, a high level of safety should be expected. It has been proven in other high-risk and complex industrial fields that obtaining very high levels of safety requires special strategies and safety philosophies in order to guarantee long-term low-risk production. The concept of safety culture has invaded many industries, more recently including medicine. Concepts of the high reliability organizations (HROs) are now ready to be adapted to medicine and offer promising improvements in health care. This paper applies some of the HRO principles to airway management and illustrates how to transform more general strategies to practical application in the clinical world. This includes the use of key elements of crisis resource management (CRM) and the development of a checklist for safety in airway management.

Summary Errors in healthcare feature in the 10 leading causes of death. The identification of the sources of such errors and the development of countermeasures whether against errors made by individuals or errors occurring due to latent conditions at system level are the key strategies in tackling this large problem. Simulation-based teaching can make meaningful contributions to this process in many ways and at many levels. At the level of the individual healthcare professional simulated clinical scenarios can raise awareness of the nature of the problem and demonstrate the relevance and need for training in a crew resource management type of course. At the level of an anaesthetic department such courses can help provide a common approach to problems in an area neglected by traditional teaching and so improve communication in this area. The use of simulation also extends to research and development. Study of the use of key resources, such as personnel or equipment, under stressful conditions in a simulated environment can help not only detect possible sources of error but can also help develop strategies to provide effective specific countermeasures.

Patient safety and errors in medicine are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a systems approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology - within which realistic simulators were developed - is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of culture throughout the entire health care system. The culture of blame focused on individuals should be replaced by a safety culture, that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a preventive and proactive safety culture should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient safety must have the highest priority in the goals of the institution: Primum nihil nocere - First, do not harm.

»Human Factors« hat sich mittlerweile zwar als Begriff eingeburgert, jedoch wird die Bezeichnung sehr unscharf verwendet und meint ganz unterschiedliche Dinge [3], [39], [40]: Es kann sowohl der »Faktor Mensch« damit gemeint sein als auch die menschliche Leistungsfahigkeit oder Bedingungen, welche durch die menschliche Psyche und die menschliche Entscheidungsfindung gegeben sind (z. B. Ergonomie von Geraten [29]). Die in ◘ Tab. 13.1 gegebene Auflistung stellt einen Versuch dar, die Begrifflichkeit der »Human Factors« zu systematisieren und in ihren Inhalten zu spezifizieren.