To err is human: use of simulation to enhance training and patient safety in anaesthesia

Abstract

Human beings who work in complex, dynamic, and stressful situations make mistakes. This is as true for anaesthetists as for any other health-care professional, but we face unique challenges in the many roles and responsibilities we have in diverse clinical contexts. As a profession, we are well versed in the development and utilization of improvement techniques and technologies that prioritize high-quality, safe care for patients. This article focuses on one particular domain of patient safety in which anaesthetists have been pre-eminent, the use of simulation in training to improve both professional capabilities and patient safety in anaesthetic practice. This review considers the impact of error in health care; the role of anaesthetists in promoting simulation-based education for the development of clinical skills and improved teamwork; and their role in disseminating human factors and quality improvement science to enhance safety in the clinical workplace. Finally, we consider our position at the vanguard of developments in patient safety and how the profession should continue to pursue a leadership role in the application of simulation-based interventions to training and systems design across health care.

The scale and impact of error in health care

The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

Don Berwick, 2013¹

Evidence confirming the existence of error in health care has been available in anaesthesia since the 1950s^2–7 and more recently in the wider health-care community.^8–11 Furthermore, health-care error has been calculated to be the third biggest killer in the USA after heart disease and cancer,¹² and similar estimates are described in many of the developed health-care systems in the world.^13–15 Awareness of the prevalence of error in anaesthetic practice, and the courage to reflect constructively on the underlying causes, has led to pioneering research and training to improve safety. Methodologies to study risk and reduce error have been developed far in advance of the other medical specialities and before publication of documents such as ‘To Err is Human’ by the Institute of Medicine in 1999¹⁶ and ‘An Organisation with a Memory’ in the UK in 2001,¹⁷ which led to greater awareness of the issue of avoidable harm amongst the wider health-care community.

Of course, the most obvious and important impact of error in health care is on the patients and their families, who suffer the physical and psychological impact of the adverse event. In the National Health Service (NHS), the tragic death of Elaine Bromiley in 2005, during anaesthesia for elective ear, nose, and throat surgery, brought the inadequacies of human factors training in health care into sharp relief.¹⁸ Elaine’s husband, Martin Bromiley, is an airline pilot, and his subsequent focus on enabling learning from the errors that were made in his wife’s case led to the foundation of the Clinical Human Factors Group (www.chfg.org; accessed 5 September 2017) and a significant and sustained increase in the awareness of the importance of human factors in the NHS.¹⁹

Patient safety and anaesthesia

The clinical workplace for anaesthetists has changed rapidly and dramatically over the past few decades. Advancements in the technologies and devices used to support patient care, patients with increasingly complex co-morbidities, the move to electronic systems of record keeping, and changes in patterns of working, coupled with an ever-increasing pressure to achieve targets, make health care a more challenging environment in which to work than ever before. It is in these complex and dynamic settings, with multiple interdependencies and the requirement for rapid decision-making in uncertain situations, that health-care professionals must strive to prevent error.

Learning from high-reliability organizations

There are numerous other industries where challenging work conditions are also regarded as potentially hazardous or high risk. Professor Karlene Roberts, who has studied the design and management of organizations in which errors can have catastrophic consequences, states: ‘to identify these organisations one must ask the following question, “how often could this organisation have failed with dramatic consequences?” If the answer to the question is many thousands of times the organisation is highly reliable.’²⁰ These so-called high-reliability organizations offer useful lessons to be drawn from their considerable efforts to drive down accident rates through research into human factors and implementation of novel systems design and monitoring strategies.²¹ Successful examples of high-reliability organizations include the nuclear fuel industry, chemical industries, and civil aviation (e.g. learning from the egregious events at Chernobyl, Bhopal, and Tenerife airport, respectively).²¹ James Reason and Charles Perrow provide eloquent insights into how such events are caused by a concatenation of behavioural and systems failures leading ultimately to catastrophe.^21–23 There is no doubt that health care is beginning to learn these lessons, but there remains a considerable distance to travel. Rene Amalberti has studied ‘ultrasafe’ industries and compared them with what he calls regulated and dangerous enterprises.²⁴ Regulated systems include driving and chartered flights, whereas dangerous systems include mountain climbing and bungee jumping (which are associated with accident rates of 1 per 1000 events). Figure 1, from Ferner's paper on medication error²⁵ extrapolates from work by Amalberti²⁴ and Leape²⁶ to compare the safety performance in healthcare with other high risk enterprises. Unfortunately, healthcare is more closely aligned with mountain climbing than civil aviation.

Safety in anaesthesia

One of the clear success stories in health care is found in anaesthetic practice, in which there has been considerable improvement in patient safety and mortality over the past 50 yr. Early reports on patient mortality suggested that deaths directly caused by anaesthesia were in the region of 1–2 per 10 000,^2,3 and that figure is now closer to 1 per 100 000.²⁷ The reasons for this improvement are multifactorial and related both to scientific developments in the field and to a broader and stronger focus on clinical governance and standards of practice. In more recent years, attention has been focused on how simulation can enhance technical training and the development of professional capabilities in anaesthetic practice. This has underpinned a desire to improve individual resilience by highlighting the importance of developing personal non-technical skills alongside improving team capabilities in the management of critical situations. Continued focus on analysis of operations through robust clinical audit has been illustrated by publication of the first compendium of audit recipes in 2000,²⁸ the Royal College of Anaesthetists’ (RCoA’s) National Audit Projects beginning in 2003,²⁹ and introduction of the Safe Anaesthesia Liaison Group (SALG), a collaborative group of organizations that aim to promote patient safety learning in anaesthesia across the UK.

This progressive attention to patient safety from the individual practitioner through to the organizational level has enabled anaesthesia as a profession to embrace the concepts and science of human factors more readily than some other parts of the health-care system. Human factors has been defined by the Health and Safety Executive as the ‘environmental, organisational and job factors, and human and individual characteristics, which influence behaviour at work in a way which can affect health and safety’.³⁰ Although originally intended to address the well-being of the worker, the impact of a human factors approach to systems design is readily extended to patient safety, productivity, and efficiency in the health-care context. The two broad domains of study under this umbrella are human behaviour and systems analysis (with considerable interdependency between the two). They provide significant opportunities for simulation-based approaches to help support the integration of human factors into education and professional practice. The remainder of this review focuses on how anaesthesia has adopted simulation-based education for training in technical and non-technical skills and considers our role in promulgating a systems-based approach to providing safer health care.

Simulation-based education in anaesthesia

Simulation training in all its forms will be a vital part of building a safer healthcare system.

Sir Liam Donaldson, CMO Annual Report (2008)³¹

Simulation as applied to health care has been defined as ‘a technique, not a technology, to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner’.³² Experiential learning is one of the key educational theories used to explain how simulation can support or enhance the transition from novice to expert professional practice. First described in ancient times by both Confucius and Aristotle and more recently by Kolb, the experiential learning cycle explores the educational psychology underpinning learning from concrete experience.³¹ Even without an understanding of formal educational principles, however, it is surely self-evident that training doctors, nurses, and allied health professionals together in a safe and supportive learning environment, where they can practice without the risk of doing any harm, is a good idea. This view is clearly supported by data collected from patients themselves.³³

Anaesthesia as a profession has been quick to recognize the potential advantages of adopting simulation as an educational concept. Careful consideration and academic review of successful learning strategies incorporating simulation has emphasized the importance of high-quality educational design and of curriculum integration, amongst other factors.^34,35

Anaesthetic leadership in simulation-based education

Anaesthetic leadership in the integration of simulation into educational and clinical settings in the UK has been vital to the development of experiential learning for health-care professionals from all backgrounds. The first centres to deliver simulation training for health-care professionals in the NHS were opened and led by anaesthetists (in Bristol and Stirling), and their pioneering activity led the way for the development of many more centres across a broad range of organizations, including postgraduate education centres in hospitals, military training centres, and higher education institutions. Even greater growth has been experienced in recent years, with the widespread use of in situ or workplace-based simulation exercises that offer point-of-care opportunities to rehearse skills and drills in the clinical setting.

The current state of simulation-based education in the UK

In 2014, a national scoping report³⁶ published by the Association for Simulated Practice in Healthcare (ASPiH) explored the spectrum of uses of simulation in health-care training in the UK and concluded: ‘It is clear Simulation Based Education is now established as an important tool in the armamentarium for training and assessing healthcare practitioners. We found many examples of excellent practice across the country at local and regional levels but lack of national strategies led to inefficiencies and variability in standards.’ This report was commissioned by the Higher Education Academy with additional support from Health Education England, and key additional findings included widespread lack of funding to support faculty development in simulation training, inadequate provision of time for training in simulation (for both faculty and participants), and lack of uniform standards and quality assurance for the provision of simulation-based education. In 2016, as a direct result of this project, ASPiH published initial guidelines for standards in simulation-based education³⁷ to provide a benchmarking framework for faculty, technical staff, and simulation facilities to help shape and assure the quality of this work.

Despite the challenges faced in implementing simulation training, our profession has been at the forefront of developing and incorporating it as a tool to improve competence in technical procedures (such as tracheal intubation and arterial and venous line insertion) and the non-technical skills which support high-quality professional practice and the effective management of crisis situations. Simulation training for technical skills in health care has been the subject of considerable research in recent years, all of which points to its value in developing competencies. It is part of the reason for the sudden upsurge in interest in incorporating simulation into specialty curricula where little existed before.

Simulation training for technical skills

The paradigm shift that has occurred in medical education in recent years has been a move from the more traditional ‘see one, do one, teach one’ mantra to a focus on outcomes-based education and specific educational design to enhance the transfer of learning to the clinical workplace. McGaghie’s 2014 review³⁸ points out that: ‘Medical education research spanning at least four decades demonstrates that simulation technology, used under the right conditions (e.g. curriculum integration, deliberate practice, rigorous measurement, feedback, faculty staff preparation, organisational support) can have large and sustained effects on knowledge and skill acquisition and maintenance among medical learners. These outcomes have been documented in a series of review articles that use varied approaches to research synthesis. Despite their methodological differences, these reviews all conclude that SBME (Simulation Based Medical Education) is highly effective, especially in comparison with no-treatment (placebo) conditions³⁹ and traditional clinical education.’⁴⁰

Evidence to support the use of simulation for training in technical skills

Research into the use of simulation to train technical skills for health-care professionals has clearly shown that development of expertise is expedited by the incorporation of part-task trainers.^38,40,41 Core skills relevant to anaesthesia, including lumbar puncture and central venous line insertion, have been studied, revealing significant differences in technical skills in relationship to sterility, correct use of manometer equipment for lumbar puncture, fewer needle passes to correct central venous catheter insertion, and a reduction in catheter-related sepsis.^42–44 Anaesthetists have been using part-task trainers (such as airway heads and plastic arms with silicon vessels) to teach airway management skills, venous access, and nerve block^45–47 for many years, and we continue to adapt this type of training according to need. A recent example is the rapid development and deployment of front-of-neck access courses in line with new Difficult Airway Society guidance for the provision of surgical airways in emergency settings. There are currently more than 30 such courses advertised on their website, ranging from use of simple simulated airways constructed from corrugated tubing and Sleek™ to training using cadavers.⁴⁸

Simulation training for non-technical skills

Simulation training in particular allows teams to practise safely and reduces the risk of complications for patients.

Dame Sally Davies, Chief Medical Officer, 2011⁴⁹

Safe care of complex or acutely unwell patients requires high levels of proficiency in both technical and non-technical skills (such as communication, leadership, decision-making, prioritization, and task management). Although there is reasonably good acceptance and availability of part-task trainers and similar technologies to support simulation-based training for technical skills, the case for non-technical skills has taken longer to become established and valued professionally. Within anaesthetics, the pioneering work to define and describe the taxonomy of non-technical skills for anaesthetists was undertaken through observation and discussion of both clinical and simulated practice.^50,51 The anaesthetic profession demonstrated its willingness to lead both on the explicit formal development of validated non-technical skill descriptors^50,52 and on incorporating them within the specialty training curriculum. Other specialities have since followed this lead using the same methodologies.^53,54

Simulation-based methods offer opportunities for the formative development of core and advanced technical and non-technical skills and are now commonplace within different stages of summative assessment at undergraduate and postgraduate level. In recent years, the General Medical Council has explored the use of simulation techniques within many of its programmes, and particularly, to support the ‘doctor in difficulty’. Simulation might offer a valuable perspective on aspects of professional capabilities alongside other forms of evidence.⁵⁵

Learning a lesson from aviation

Civil aviation is often cited as an analogue to anaesthesia where human performance is concerned, and this is certainly the case in some domains. Similarities exist in the long periods of relative inactivity and low cognitive load interspersed with moments of extremely high tension, and the need to work effectively in teams where skill mix and competence will change on a day-to-day basis. In 1979, a seminal paper was published by The National Aeronautics and Space Administration⁵⁶ clearly describing how teams of very experienced airline crews mishandled what should have been a straightforward problem, not because they were technically inept, but through sub-optimal leadership, communication, and decision-making.

All of these issues resonate with published reviews of incidents in anaesthesia in recent years, and the lessons we might learn from aviation were highlighted in a review of the subject.⁵⁷ Part of the solution to the problems so clearly highlighted by Ruffell-Smith’s work was to implement compulsory, regular simulation training for multidisciplinary (cockpit and cabin) aircraft crew. This training is known as Crew (initially Cockpit) Resource Management (CRM) training. It combines didactic training in the characteristics of aviation systems and processes with experiential training for combined teams of cockpit, cabin crew, and maintenance personnel in highly realistic simulators. Data to support the success of CRM training in improving teamwork and behavioural changes in the workplace exist^58,59 and, since 1989 (after the Kegworth air disaster),⁶⁰ when CRM training was implemented for UK airline crews, there has not been a single death on a British aircraft.⁶¹

Crisis resource management training in anaesthesia

The first interactive patient simulator for team training in health care, Sim One, was developed in Southern California in the mid-1960s.⁶² Unfortunately, it was prohibitively expensive to manufacture, and as a result, simulation training for teams did not attract significant attention until a manikin for use in CRM training in anaesthesia was constructed in Stanford in 1987.⁶³ This group went on to develop and run the first anaesthesia CRM course in 1990 (based on experience of similar training in civil aviation),⁶⁴ which focused on enhancing non-technical skills in multidisciplinary teams.

Rhona Flin (an industrial psychologist at the University of Aberdeen) has defined non-technical skills as ‘the cognitive, social, and personal resource skills that complement technical skills, and contribute to safe and efficient task performance. They are not new or mysterious skills but they are essentially what the best practitioners do in order to achieve a consistently high performance and what the rest of us do on a good day.’⁶⁵ She described a further division of these skills into two subgroups: cognitive skills (e.g. decision-making, planning, and situation awareness) and social skills (e.g. communication and team working). It is estimated that 70–80% of errors in health care are attributable to failings in these domains.⁶⁵ In 2003, Maran and Glavin⁶⁶ described how the expansion in availability and types of simulation modalities provided an opportunity for technical skills, non-technical skills, and teamwork training approaches to be integrated into curricula in addition to offering continuing professional development for clinicians. However, the uptake and implementation of this vision has been relatively slow within the profession and at the organizational level within hospital settings. This is demonstrated well by the 4th National Audit Project (NAP4) of the Royal College of Anaesthetists in 2011, which explored ‘Major Complications of Airway Management in the United Kingdom.’⁶⁷ It is clear from the findings that sub-optimal judgement and lack of training were significant contributors to the evolution of the critical incidents described in the report, and human factors training incorporating simulation featured prominently in the recommendations.

Evidence to support simulation training for non-technical skills

David Gaba, one of the foremost pioneers of simulation training in anaesthesia, published a paper in 1992 in which he reported disappointingly high levels of failure in the management of common emergency situations (in a simulated environment) amongst residents in anaesthesia and commented: ‘… no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it.’⁶⁸ This worthy sentiment was appreciated by frustrated educators in health care. Fortunately, it is now underpinned by evidence of enhanced performance and, more importantly, improved patient outcomes after simulation training.

A recent review of team training in health care highlighted the upsurge in publications on the subject over the past decade (Fig. 2). It also found that programmes (incorporating simulated practice) delivered significant benefits in team performance, medication and transfusion errors, and patient outcomes.⁶⁹ Interventions incorporating simulation were even more likely to produce a positive impact where they were supported by ongoing workplace initiatives after the training had taken place. Examples include: support for staff to deliver quality improvement in the workplace; mentorship to sustain and develop leadership skills; ongoing monitoring and evaluation of outcomes from training; and implementation of tools designed to reinforce learning outcomes in the workplace.

Valid criticisms have been levelled at the design, implementation, and analysis of team training interventions in health care in the past.^70–72 But medical centres associated with the Veteran’s Administration (who implemented the Patient Safety Medical Team Training programme) and hospitals that have used the TeamSTEPPS™ system (Team Strategies and Tools to Enhance Performance and Patient Safety, sponsored by the Agency for Healthcare Research and Quality and the Department of Defence in the USA) had the ability to implement a standardized package of training across their organizations and showed significant benefits in terms of patient outcomes, including surgical morbidity and mortality.^73–77 Evidence to support improved outcomes for patients where standardized and sustainable team training and quality improvement interventions are used now exists, but data have come largely from other countries (most notably the USA). There is a clear need to provide similar results within the NHS.

Non-technical skills training for health-care professionals in the NHS

Despite evidence that team training programmes in health care improve both team performance and patient outcomes, they have not yet been widely adopted in the NHS. A recent review of training curricula across the postgraduate medical Royal Colleges in the UK showed that very few referenced non-technical skills explicitly, let alone classified them as core competencies.⁷⁸ The Curriculum for a Certificate of Completion of Training in Anaesthesia (the RCoA’s curriculum for completion of training in anaesthesia in the UK) had five times as many references to human factors as the closest nearest curriculum (Emergency Medicine) and a whole section of the curriculum given over to human factors in clinical practice. More importantly, the RCoA’s curriculum document highlights the fact that safety is the consistent theme that permeates the entirety of anaesthetic training and states: ‘measures to help ensure safe practice have been incorporated into the fabric of anaesthesia, which are emphasised to each new generation of anaesthetists. Specific competencies relating to patient safety are included in every section of the curriculum. There is therefore no specific section of learning devoted to safety.’

It is abundantly clear to those of us employed as clinicians in the NHS that more often than not we work in teams of experts and do not always function as expert teams. Multidisciplinary health-care professionals are expected, on an ad hoc basis in both elective and (more commonly) emergency settings, to perform with seamless efficiency in the context of having little knowledge of the skills or competencies of the colleagues with whom we will be working.^65,79 If we are to continue to accept this situation as the norm and rely on serendipity rather than resilience to ensure high standards of care then avoidable harm rates will surely remain as they are. It is imperative that we train together to improve our teamworking skills and behaviours. There is no doubt that anaesthesia has led the way in the design and delivery of team training, but there is still a long way to go before we are providing the opportunity for multidisciplinary teams to access well-designed, fully immersive simulation exercises regularly.

Human factors: the science of systems analysis and design for safer anaesthesia

Given the inherent unreliability of the (healthcare) system it now seems remarkable that there are so few adverse events, which is probably testament to the resilience and powers of recovery of clinical staff.

Vincent and Amalberti, 2016⁸⁰

The consequences of adverse events in health care can be negligible or, in contrast, catastrophic. They involve patients, families, and carers, but can also have significant negative impact on the clinical staff involved and on an organization’s finances and reputation. When serious incidents are investigated, the themes that emerge reveal the same, limited number of key issues, which include: inadequate or inconsistent standard operating procedures, lack of team training for staff, steep authority gradients creating difficulty in ‘speaking up’, and lack of surplus equipment or staff.⁶¹ There is a growing recognition that such investigations in health care are conducted in an imperfect manner and may lack crucial pieces of factual information about events that occurred.⁸¹ High-reliability organizations have demonstrated the value of applying human factors science and its associated methodologies, some of which have been adapted for health care (such as Failure Modes and Effects Analysis, FMEA,⁸² and Systems Engineering Initiative for Patient Safety, SEIPS)^83,84 in mitigating the risks of error.

Understanding error and safety

The discipline and study of human factors began in earnest during the Second World War. It was recognized that as scientific advancements in warfare delivered more technologically complex equipment for humans to use the expected benefits were not realized because soldiers were unable to understand or use the more complicated weaponry. An obvious analogy exists in medicine, where equipment, medication, and treatment modalities change rapidly without the clear focus that exists in other domains to design systems around the human–device interface. An increasing desire for providing information technologies to reduce reliance on traditional paper-based documentation matches similar trends in society, but healthcare does not yet have the embedded methodologies or culture of pursuing a user-centred approach to the design of such interfaces. Providing optimal care for patients presenting with complex problems and extensive co-morbidities in overburdened, under-resourced, and inadequately designed systems leads to error, potential harm, and waste in the use of resources to support care.²²

A growing academic and professional interest in resilience within health-care organizations is becoming apparent in the current financial climate.⁸⁵ We must understand better how health care can be delivered more efficiently and productively despite these challenging conditions. One theme emerging within organizational resilience is the concept of ‘Safety 1 versus Safety 2.’⁸⁶ The traditional patient safety paradigm (Safety 1) has been to scrutinize serious incidents to identify and learn from specific root causes of harm and to share them at local or system-wide levels. In a Safety 2 approach, there is greater interest in understanding how things ‘go right’ and in paying closer attention to the adaptability and flexibility that the system demonstrates to avoid untoward events. This approach celebrates the humans in the system by acknowledging how they help to create safety under such a spotlight, rather than their role in events culminating in serious harm.

Simulation has an enormous amount to offer these endeavours to improve the safety of the systems in which we work. Whether in the form of simple table-top exercises or as fully immersive drills in a real clinical area, simulation can help to diagnose problems in care pathways and can stress test policies, procedures, and processes safely without the risk of harm to patients. A significant amount of this work is currently being undertaken at local levels, although currently it tends to focus on the skills (technical and non-technical) and team behaviours of the clinical practitioners rather than the design and safety of the system in which the work is being conducted. Data are emerging in the literature to illustrate potential benefits when methodologies focused on systems improvement are embedded in the local policies and professional culture of the clinical services, although the approach is not without its challenges when conducted in busy, complex environments.^87,88 Of course, it is exactly these environments and work conditions in which the benefits might be most apparent and where the greatest effort should be focused.

Future directions

… simulation offers an important route to safer care for patients and must be more fully integrated into the health service.

Dame Sally Davies, Chief Medical Officer, 2011⁴⁹

In a nationalized health-care system, it may be a reasonable expectation of society that standardized, context-specific simulation training could be implemented for health-care professionals from all backgrounds, but this is not yet the case in the NHS. Perhaps the greatest challenge facing the simulation-based education community is to consider how to ensure its widespread adoption and sustainability in an increasingly fiscally constrained health-care system. Furthermore, the various educational organizations and regulatory bodies that commission and oversee the quality and delivery of training for health-care professionals are struggling to provide a uniformity of ambition or clarity of curricula requirements.

Simulation in perioperative medicine

The data on patient safety would suggest that we are seeing positive results in some areas of health care, such as meticillin-resistant Staphylococcus aureus septicaemia and improved incident reporting and analysis, but challenges to such improvements continue to emerge. Staff are reporting a worsening of the culture of blame, and 40% of patients report a lack of nursing staff on the wards.⁸⁹ Faced with these challenges and the need to pursue high-quality care with limited resources, the RCoA is developing a collaborative programme for the delivery of perioperative care in the UK⁹⁰ and simultaneously considering the professional role that anaesthetists might play in the future. The vision document for this programme clearly highlights the complex interdependencies in primary and secondary care for patients undergoing surgery and states: ‘the multidisciplinary team can be led by doctors from various specialities including anaesthesia, surgery, acute medicine, cardiology and care of the elderly … GPs and surgeons will have a single point of contact to ensure the individual needs of complex patients are carefully coordinated.’ The document also makes it clear that there is no perfect model for perioperative medicine in health care as yet.⁹¹ It is, however, imperative that this programme aligns our professional capabilities with our extensive experience in integrating simulation into innovative educational strategies and improving systems design to ensure a sustainable approach to the delivery of better and safer perioperative care.

Advances in technology to support simulation training

Professional and commercial colleagues in the world of engineering, computer technology, and psychology are opening up a world of novel, cost-effective, and highly portable solutions to support simulation as a tool for training and systems improvement. Taking simulation to the workplace is becoming the norm and needs to be harnessed as a force to improve the design and delivery of high-quality, safe patient care. There are also significant advances being made in the development and availability of virtual and augmented reality simulations and technologies (https://i-lab.harvard.edu/ar-vr/; accessed 5 September 2017) that can offer us many different options for learning about clinical conditions, procedural skills, and systems of care.

Conclusions

Anaesthetists can be justifiably proud of their role in developing and using simulation in health care to enhance education and training of all health-care professionals and promoting the integration of human factors methodologies in the design of safer systems. This is an important anniversary year for our profession in the UK, and it is not the time to rest on our laurels.

The novel educational tools now available are creating extraordinary flexibility in the development of innovative learning opportunities in clinical care and quality improvement. As a profession, we are perfectly placed to amplify the benefits of advances in simulation through collaborative research into training interventions and systems design that demonstrate a clear impact on patient outcomes and organizational resilience. It is vital that we continue to lead in this domain.

Author contributions

Conception and design of article; writing up first draft and revising subsequent iterations of the manuscript; critical revision and final proofreading: H.H.

Review of the conception and design of article; critical revision and substantial contribution to subsequent iterations of the manuscript; final proofreading: B.B.

Declaration of interest

Both authors have been President of the Association for Simulated Practice in Healthcare, B.B. from 2008 to 2014 and H.H. from 2014 to 2017. H.H. is Medical Director of Oxford Simulation, Teaching and Research. B.B. is Medical Director of Trent Simulation and Clinical Skills Centre.

References