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The Role of Simulation When Onboarding Healthcare Professionals—Part II

Problem: Simulation is an evidence-based teaching method that can help facilitate the learning of important safety and quality aspects of patient care by replicating a process or system in a safe environment to gain insight. While learning from mistakes is an important part of new hire orientation, involving a patient might risk safety. Even while shadowing seasoned staff, there will never be sufficient opportunity to experience all the complex situations that new hires will eventually face. New practitioners may not be able to observe error-prone scenarios or practice critical tasks under the guidance of a mentor if the critical tasks do not happen during their orientation. It is also likely that situations will be missed in which patients present with rare diseases and corresponding medication therapy.

Current staffing levels and high patient acuity may not allow for an adequate amount of time dedicated to teach new hires and they may be pressured into uncomfortable situations before they are ready. So, during onboarding, how can we add to the new hire’s knowledge so they can apply it to clinical practice? Furthermore, how can we best use mistakes that were made in the hospital and from external sources to show new practitioners how they can learn from them? In Part I, we presented how to promote a safety culture during the onboarding process. In Part II, we discuss the role of simulations in new hires' medication safety education.

Understanding Simulation

Simulation has been used in many industries such as aviation, spaceflight, nuclear power, shipping, military, and sports. These industries are often held up as examples when it comes to risk mitigation and safety. Simulation in healthcare can be used to prepare staff to properly perform certain tasks or processes, utilize critical job-specific tools/devices (e.g., infusion pumps, automated dispensing cabinets [ADCs], compounding technology), or identify and troubleshoot failure modes (e.g., dose error, technology downtime). ISMP has advocated for the use of simulation for certain scenarios highlighted in the following articles: Survey results from pharmacists provide support to enhance the organizational response to codes; Emergency preparedness: Be ready for unanticipated electronic health record (EHR) downtime; Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers; and Prevent uncontrolled, rapid infusion rates: Confirm infusions are connected to pumps before opening the clamp!

Simulation as Part of Healthcare Education

The National Council of State Boards of Nursing (NCSBN) National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education assessed the impact of simulation on educational outcomes in student practitioners. New nursing students were randomized into three groups: a traditional clinical program (control), and students who had either 25% or 50% of their clinical hours replaced by simulation. The students remained in their group for all core clinical courses in their program and were followed for 6 months after graduation, during their first position as a registered nurse (RN). They found that substituting up to 50% of traditional clinical experience with high-quality simulation produced comparable educational outcomes in core nursing courses.

In another study by Advocate Aurora Health, a medication safety “escape room” was used as part of a training module for pharmacists and pharmacy technicians.1 The escape room included concepts of barcode scanning, look- and sound-alike medications, high-alert medications, and calculations. This allowed for errors to be simulated in a controlled environment to increase medication safety knowledge. Participants reported that the simulation was more engaging than the alternative online self-paced learning modules, as they were communicating with colleagues to escape each room.

What is missing in healthcare practitioner educational programs is a bridge between classroom learning and real-life clinical experience. Simulation can provide such a bridge and protect students from work-related dangers (e.g., infected needles, blades, electrical equipment). Educators can also use simulation to emphasize realistic situations by putting more stress and pressure on practitioners to perform a task. For example, rather than reading about how to administer an injection, new practitioners can practice preparing and administering a vaccine by drawing it up from a demonstration vial using a needle and syringe and injecting into an orange or foam pad. Using simulation to enhance learning can also be used to ensure competency. Consider the difference between requiring a surgeon to pass a written multiple-choice exam on how to perform laparoscopic surgery and having them demonstrate the use of the actual technology in a simulated environment.

Safe Practice Recommendations: Knowing that every organization has limited resources, consider the following recommendations when formalizing or incorporating medication safety simulation into your educational programs:

Start with what you have. The healthcare educator who oversees new practitioner onboarding should identify what simulations are already being performed but are not distinguished as a “simulation” (e.g., sterile compounding, programming smart infusion pumps, patient counseling, emergency downtime drills) and incorporate it into a formalized simulation process.

Expand content. Develop simulation videos for staff that involve the identification of medication errors (e.g., sterile compounding with errors in technique, overriding an alert in the dose error-reduction system [DERS] when programming a smart pump). In our June 1, 2006 newsletter, we wrote about creating a “room of horrors” with a simulated patient and chart, set up with common items and mistakes that can lead to patient harm. Consider developing simulations to address actual errors that have occurred in your facility or those that have appeared in the ISMP Medication Safety Alert! Consider including the following errors or hazards as simulation scenarios: selecting the incorrect patient profile in the EHR or ADC, not reading back a verbal order, confusing look-alike medication packaging, preparing an oral medication in a parenteral syringe, administering the wrong medication using an unlabeled syringe, or a misconnection due to not tracing an infusion line before connecting it to the patient.

Use simulation to ensure competency. Develop simulation programs to ensure competency when new staff perform essential medication-related tasks. Provide ongoing simulation opportunities when introducing new procedures or improving how infrequent tasks should be accomplished. The healthcare educator should repeat the simulation with different variables until the learner has become skilled. Once this is mastered, incorporate additional elements such as noise, distractions, and interruptions to better replicate a realistic work environment. Simulated distractions can make staff aware of the impact these can have on their processes. In one school of nursing where students participated in simulations with varied background noises (e.g., music, conversations) and noise levels, the students found that distractions decreased accuracy in medication preparation and administration and led them to take additional time to check their calculations.2

Use simulation to validate new processes or technologies. Use simulation to evaluate updates to technologies (e.g., prescribing using new order sets, pump library updates, new drugs or formulations in intravenous [IV] workflow management systems). You can also simulate new workflow processes to test what does and does not work, gain crucial feedback from frontline staff, and identify any potential safety gaps before rolling out large scale changes. Consider having “a day in the life” to run real-life simulations of new technologies/devices to see how they work in your clinical settings with your staff, compared to testing environments utilized by vendors.

Collaborate with various disciplines. Partner with other healthcare practitioners in medication safety simulations (e.g., code response, malignant hyperthermia, EHR downtime), and practice teamwork behavior (e.g., managing high workload, coordinating under stress, effective communication).

Debrief. After each simulation, incorporate a formal debriefing.3 Provide a safe learning environment for staff to discuss what occurred during the simulation scenario. Explain any “missed” errors to the participant(s) and allow them to ask questions, share concerns, and review what could be improved upon to determine how to better approach future simulations and medication safety processes.

Partner with colleges and universities. All educational programs in healthcare-related professional schools should include a course on medication safety. Ideally, these courses should also incorporate simulations that include common unsafe medication-related processes, medication errors, and high-risk scenarios. Reach out to affiliated or local colleges/universities and ask about the use of simulations in the curriculum. Consider partnering with them to develop ways to strengthen these programs.


  1. Kasal T, Sabol K. Novel medication safety training module. Am J Health Syst Pharm. 2022;79(Suppl 4):S123–27.
  2. Thomas CM, McIntosh CE, Allen R. Creating a distraction simulation for safe medication administration. Clin Simul Nurs. 2014;10(8):406-11.
  3. Thomas Dreifuerst K. Getting started with debriefing for meaningful learning. Clin Simul Nurs. 2015;11(5):268-75.


Suggested citation:

Institute for Safe Medication Practices (ISMP). The role of simulation when onboarding healthcare professionals—Part II. ISMP Medication Safety Alert! Acute Care. 2023;28(9):1-3.