In‑Situ Simulation Scenarios & Debrief Guides

How to use this Scenario Bundle

These scenarios are designed to be run in clinical settings to reveal latent safety threats (LSTs), test real workflows, and build team skills while minimizing disruption to care. Each scenario includes: learning objectives, setting/context, patient presentation and initial vitals, a scripted timeline with injects, role assignments, simulated equipment list, expected critical actions, assessment checkpoints, and debrief facilitation guidance. Use the Data Capture Template to record system issues and assign owners. After each run, capture outcomes, owners, and closure dates.

Scenario A — Cardiac Arrest on Medical Ward

Learning objectives

• Recognize cardiac arrest and initiate high-quality CPR and defibrillation per ACLS priorities.
• Demonstrate clear role assignment and closed-loop communication during resuscitation.
• Identify system barriers to rapid defibrillation and medication delivery (equipment, location, team coordination).

Setting & context

Adult patient on a step-down ward. Staffing: 1 RN primary, 1 RN secondary, MD on-call, unit clerk, respiratory therapist (RT) available. Scenario launched without prior notice to clinical team (low-disruption flag as required by site policy).

Patient presentation (start)

Timeline & injects (5–8 minutes)

1. 0:00 — Team discovers unresponsive patient. Expect immediate call for help and assessment.
2. 0:30 — Monitor shows VF; expect CPR and call for defibrillator. If defib delayed >90 sec, inject: equipment not found; nurse must request crash cart from opposite corridor.
3. 2:00 — Defibrillation attempt; if done within target times, progress to medication schedule. If not, debrief will highlight system delays.
4. 4:00 — ROSC simulated if correct sequence followed; if not, scenario ends for debrief.

Roles

• Team leader (senior nurse or physician)
• Compressor (CPR)
• Airway manager (RT/clinician)
• Defibrillator operator
• Medication nurse/documenter
• Observer(s) — checklist & system gap recorder

Simulated equipment

• Defibrillator (real or training device)
• Crash cart with simulated drugs (label clearly non-pharmaceutical)
• Ambu bag, airway adjuncts
• Task-trainer or manikin appropriate for ward environment

Expected critical actions (for assessment)

• Immediate recognition and call for help.
• High-quality compressions with minimal interruptions.
• First shock delivered within target time (site-defined).
• Clear role allocation and closed-loop communication.
• Post-resuscitation plan initiated and documented.

Scenario B — Early Sepsis Recognition in ED Triage

Learning objectives

• Recognize early signs of sepsis at triage and escalate appropriately.
• Demonstrate timely use of sepsis screening tools and rapid initiation of bundle elements (fluids, cultures, antibiotics) when indicated.
• Surface system issues: lab turnaround, antibiotic access, triage-to-bed delays.

Patient presentation

Older adult with fever, confusion, tachycardia. Vital signs: HR 120, BP 92/58, RR 24, SpO2 94% RA, Temp 38.9°C. Triage nurse uses screening tool and must decide next steps.

Key injects

• Delay in IV access simulated if team does not escalate—inject: limited IV supplies or competing workload.
• Lab turnaround >60 min if ordering workflow not used correctly (system gap).

Assessment checkpoints

• Was sepsis recognized within target time?
• Were cultures obtained before antibiotics when clinically possible?
• Time to first antibiotic documented.

Scenario C — Airway Emergency in PACU

Learning objectives

• Recognize and manage an acute airway obstruction.
• Use available airway equipment and escalate to advanced airway per local protocols.
• Identify handoff and communication gaps between anesthesia and PACU staff.

Patient presentation

Post-operative patient with sudden hypoxia and decreasing consciousness in PACU. SpO2 dropping to <85% within 2 minutes. Team must assess and secure airway.

Critical actions

• Immediate oxygenation and basic airway maneuvers.
• Call for anesthesia backup and prepare advanced airway tools.
• Document actions and identify delays in bringing specialized equipment.

Debrief Facilitation Guide (structured)

Use a 3-phase debrief to respect time and maximize learning: Reaction — Analysis — Summary. Keep tone nonjudgmental; focus on system and team performance rather than individual blame.

1) Reaction (1–2 minutes)

• Ask participants for immediate impressions: "How did that feel?"
• Acknowledge emotions; re-establish psychological safety.

2) Analysis (8–12 minutes)

• Reconstruct timeline with the team; ask target questions: "What were your priorities at minute 0:30?"
• Use specific assessment checkpoints from the scenario to guide discussion.
• Human-factors prompts to explore: communication clarity, leadership, resource access, workspace ergonomics, competing priorities, cognitive load.
• Ask: "What system issues prevented the team from meeting the expected critical actions?"

3) Summary & Action Planning (3–5 minutes)

• Identify 1–3 tangible system fixes or experiments. For each: owner, due date, and quick success metric.
• Agree on how fixes will be reported and tracked (use the Data Capture Template).

Human-factors prompts (examples)

• Were roles explicit and understood?
• Where did communication breakdowns occur?
• Did the workspace layout hinder equipment access?
• Were checklists or protocols visible and useful?
• Were there competing tasks that diverted attention from patient-critical actions?

Data Capture Template — Latent Safety Threats & Corrective Actions

Use this template after every run. Record person-level learning separately from system issues. Ensure each corrective action has an owner and a target completion date.

Suggested Schedule & Metrics

Recommended cadence: start with 1–2 in‑situ runs per unit per month, alternating times (day, night, shift change) to sample different staffing patterns. Keep sessions 20–40 minutes including a brief structured debrief.

Key metrics (examples)

• Number of LSTs identified per simulation (target: >0 — indicates meaningful exposure of risk).
• Time to recognition metric (e.g., time-to-CPR, time-to-first-shock) — track median and target improvement.
• Proportion of corrective actions with an assigned owner within 48 hours (target: 100%).
• % corrective actions closed by agreed due date (target: progressive improvement).
• Participant-reported psychological safety (simple post-run yes/no question).

Safety, Ethics & Practical Tips

• Communicate with unit leadership before runs; post clear signage during an in‑situ simulation to avoid confusion with real patients.
• Obtain required permissions and follow privacy and consent policies for staff observation.
• Prioritize psychological safety: pre-brief that the scenario focuses on systems and teamwork, not individual blame.
• Minimize clinical disruption by choosing low-activity windows and having a clear stop rule if real patient needs arise.
• After action: enter LSTs into your improvement system and follow up in formal QI workflows.

Next steps & Adaptation

Start small: pilot one scenario on a single shift, capture 3–5 LSTs, close 1–2 quick fixes, then scale. Tailor scripts, timings, and metrics to local protocols (ACLS, sepsis bundles, airway algorithms). Consider packaging this bundle into a unit-specific toolkit that includes local contact lists, equipment maps, and links to reporting systems.