Some procedures are high-risk, but low-volume. Thus, ED staff need to find a way to keep rarely used skills current. “Skills deteriorate with time. If you don’t use them, you definitely lose them,” says Barbara M. Walsh, MD, director of pediatric emergency medicine in situ and mobile outreach simulation at Boston Medical Center.

For EDs, “simulation is an obvious source of risk mitigation,” says Stephanie Stapleton, MD, assistant professor and director of emergency medicine simulation at Boston University School of Medicine.1 Unlike EDs, simulation is used commonly in OB/GYN, anesthesia, and surgery. Multiple studies have shown reduced malpractice risks in those fields.2-5 When it comes to linking simulation to lower liability, “other specialties are way ahead of emergency medicine,” Stapleton observes.

Simulation is a way for ED providers to practice uncommon procedures such as intubation, central lines, umbilical vein catheters in neonates, cricothyrotomy, pericardiocentesis, pediatric resuscitation, and vaginal deliveries. Heart attacks and strokes are commonplace in EDs. “But critically ill kids are few and far between,” Walsh notes.

Most children present to general EDs.6 True critical emergencies in pediatrics are uncommon, even at children’s hospitals. “If we don’t keep up those skills, we aren’t going to be prepared and ready when a really critically ill child comes,” Walsh warns.

The health system’s malpractice insurer helped fund a state-of-the-art simulation center so ED providers could practice low-volume, high-risk procedures. “If a bad outcome happens, we can help the team figure out how to investigate it and prevent it from ever happening again,” Stapleton reports.

Of course, not all EDs have access to a fully staffed simulation center. “There are huge simulation labs that are very fancy, but it’s not what everybody needs,” Stapleton explains.

EDs can make do with a mannequin, an available resuscitation room, and a skilled debriefer. “It’s not perfect, but it’s good enough,” Stapleton adds.

The right mindset is more important than access to specific resources. “You need to have a culture [in which it is] OK to practice rare procedures and reflect on your mistakes in a meaningful way,” Stapleton says.

The importance of simulation to reduce risks is underscored because many community hospitals closed their pediatric and obstetric units.7,8 This means EPs need to independently manage these patients, and stabilize for transfer. “This is within our scope of practice. But sick children and obstetric emergencies are high-risk and low-frequency events,” Stapleton says.

Most academic centers use simulation, as it is standard practice for trainee and student education. “Community EDs use simulation variably,” Stapleton reports.

Some do not use any simulation; other EDs use it in a limited way for nursing or procedural skills. A few EDs run simulation cases. “Simulation is really a huge part of medicine for education and training,” Walsh says. “But its most powerful use is risk management and safety.”

This distinction becomes important when justifying an investment of time and money in simulation. “No one wants to pay for training and education. But if you call it risk management, which is really what it is, that changes how people look at it,” Walsh offers.

At Boston Medical Center, simulations are conducted in the trauma bay several times a month. “We run very high-level cases that really tax our systems. It makes us think about how we designed our rooms, or if something isn’t right or is missing,” Walsh explains.

Cases cover neonatal, pediatric, adult, obstetrics, and airway emergencies. “With simulation, we are able to look at where errors might occur, where things didn’t happen that should have,” Walsh says.

The ED team finds the deficits, and makes the necessary changes. “The goal is to have a good outcome for any type of patient who walks through the door,” Walsh adds.

There are some issues that were identified in simulated cases:

ED providers cannot give fluid or antibiotics as quickly as needed to a pediatric patient. “They are not thinking about how to maintain access, or not prioritizing things in the right order,” Walsh suggests.

Some EDs are unprepared for deliveries with complications. “Deliveries in the ED are a high-risk area for liability,” Walsh notes.

Walsh is developing a simulation of a dual resuscitation of a mom and baby who both need resuscitation simultaneously. EPs in rural areas rarely see women who deliver with complications. EDs in large academic centers see these cases more often. “But we have obstetric and pediatric colleagues to help us, so we rarely handle these cases solo,” Stapleton explains.

Some EDs cannot administer a large volume of fluid to a septic child quickly. Many ED providers assume they can put fluids in a pump like they do with adults. “If you just run the fluids, the child is not going to do as well,” Walsh cautions. “We teach them to use a three-way stopcock, and it’s key to resuscitating that kid.”

Supplies take too long to locate. In one simulated case, nobody could locate the Magill forceps to remove a foreign body from a child’s airway. In another case, an intraosseous device was needed to resuscitate a critically ill patient, but it was locked up in the automated medication dispenser. Staff needed to pull the item, then rush back to the trauma bay. “That is inefficient and adds to the stress,” Walsh says.

The solution was simple: stock the device on the code cart. Another identified problem involved a medication that took too long to make up. “There might be a different medication they can use to buy time while the drip is made up,” Walsh suggests.

Communication is too vague. “Simulation isn’t just for muscle memory and hands-on stuff. It’s also used for how to communicate,” Stapleton says.

Teams find some things do not work as well as they assumed. Something stated was not heard, was too vague, or was misunderstood. A page is not sent appropriately to the OB team during a neonatal resuscitation, or verbal orders are unclear. In one case, the EP asked a nurse to turn the sedation “up,” but the nurse heard “off.” The EP saw the problem and pointed up, stating “Increase.” This led to the use of “increase” instead of “up.”

During a simulated resuscitation, a nurse stated, “I need epi.” Several team members looked for the drug simultaneously, while others did not react at all. The problem was the nurse needed to identify a certain person to find the epinephrine, and instruct them what to do next.

Good communication would sound something like this: “Jill, I need you to get me code dose epi.” “I have the epi. Do you want me to push it?” “Yes, I want you to push it.” “OK, the first dose of epi is in.”

“This gets everybody on the same page during the resuscitation,” Walsh says.

During another simulated resuscitation, multiple people on the team were unclear on whether certain medications had been given, and if so, when. “The team members need to state what they think is going on,” Walsh stresses.

For instance, if a patient is in septic shock, some team members might wrongly assume they are dealing with a pneumonia patient with stable vital signs. A team member should state clearly, “This is uncompensated septic shock.”

“That changes the whole focus. It means the patient is critically ill, and we have to act now,” Walsh says.

Ideally, simulation keeps terrible mistakes from happening in the first place. “Simulation might cost tens of thousands upfront, but it could help you avoid a $20 million payout in the future,” Stapleton says.


  1. Walsh BM, Wong AH, Ray JM, et al. Practice makes perfect: Simulation in emergency medicine risk management. Emerg Med Clin North Am 2020;38:363-382.
  2. McCarthy J, Cooper JB. Malpractice insurance carrier provides premium incentive for simulation-based training and believes it has made a difference. Anesthesia Patient Safety Foundation Newsletter 2007:22.
  3. Ecker E, Moller J, Lagnese J, et al. A twofold approach: Integrating simulation and risk management training. Obstetrics & Gynecology 2016;127:41S.
  4. Riley W, Meredith LW, Price R, et al. Decreasing malpractice claims by reducing preventable perinatal harm. Health Serv Res 2016;51:2453-2471.
  5. Hanscom R. Medical simulation from an insurer’s perspective. Acad Emerg Med 2008;15:984-987.
  6. Ames SG, Davis BS, Marin JR, et al. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics 2019;144:e20190568.
  7. Hung P, Kozhimannil KB, Casey MM, Moscovice IS. Why are obstetric units in rural hospitals closing their doors? Health Serv Res 2016;51:1546-1560.
  8. Chang WW. The rapidly disappearing community pediatric inpatient unit. The Hospitalist, July 12, 2018.