S I M U L A T I O N
T R A I N I N G
CONTENTS
ANESTHESIA: SURGICAL TEAM SCENARIO ....................................... 1
Scenario Background ........................................................................................... 1
Information for the Facilitator ..................................................................................................... 1
Learning Objectives .............................................................................................. 1
Target Participants ............................................................................................... 2
Expected Outcomes ............................................................................................ 2
Facilitator Notes ................................................................................................... 2
Equipment and Supplies ..................................................................................... 3
Scenario Setup ...................................................................................................... 4
Patient ................................................................................................................................................. 4
Room ................................................................................................................................................... 4
Scenario Commencement .................................................................................. 4
Handoff Report for Participants ................................................................................................. 4
Scenario Steps ....................................................................................................... 5
Patient Response and Participant Actions ............................................................................. 5
Debrief ..................................................................................................................... 6
Resources ............................................................................................................... 6
BEHAVIORAL HEALTH: DE-ESCALATION SCENARIO ..................... 9
Scenario Background .......................................................................................... 9
Information for the Facilitator .................................................................................................... 9
Learning Objectives ............................................................................................. 9
Target Participants ............................................................................................. 10
Expected Outcomes .......................................................................................... 10
Facilitator Notes ................................................................................................. 10
Equipment and Supplies ................................................................................... 10
Scenario Setup .................................................................................................... 10
Patient ............................................................................................................................................... 10
Room ................................................................................................................................................. 10
Scenario Commencement ................................................................................ 10
Handoff Report for Participants ............................................................................................... 10
Scenario Steps ....................................................................................................... 11
Patient Response and Participant Actions ............................................................................. 11
Debrief .................................................................................................................... 12
Resources .............................................................................................................. 12
EMERGENCY MEDICINE: PEDIATRIC PATIENT SCENARIO ............ 15
Scenario Background ......................................................................................... 15
Information for the Facilitator ................................................................................................... 15
Learning Objectives ............................................................................................ 15
Target Participants .............................................................................................. 16
Expected Outcomes ........................................................................................... 16
Facilitator Notes .................................................................................................. 16
Equipment and Supplies .................................................................................... 17
Scenario Setup ..................................................................................................... 17
Patient ................................................................................................................................................ 17
Room .................................................................................................................................................. 17
Scenario Commencement ................................................................................. 17
Handoff Report for Participants ................................................................................................ 17
Scenario Steps ...................................................................................................... 18
Patient Response and Participant Actions ............................................................................ 18
Debrief .................................................................................................................... 19
Resources .............................................................................................................. 19
HEALTHCARE PRACTICE: EMERGENCY SCENARIO ....................... 21
Scenario Background ......................................................................................... 21
Information for the Facilitator ................................................................................................... 21
Learning Objectives ............................................................................................ 21
Target Participants .............................................................................................. 21
Expected Outcomes .......................................................................................... 22
Facilitator Notes ................................................................................................. 22
Equipment and Supplies ................................................................................... 23
Scenario Setup .................................................................................................... 23
Patient ............................................................................................................................................... 23
Room ................................................................................................................................................. 23
Scenario Commencement ................................................................................ 23
Handoff Report for Participants ............................................................................................... 23
Scenario Steps ..................................................................................................... 24
Patient Response and Participant Actions ........................................................................... 24
Debrief ................................................................................................................... 25
Resources ............................................................................................................. 25
MEDICAL-SURGICAL NURSING: SEPSIS SCENARIO ...................... 27
Scenario Background ........................................................................................ 27
Information for the Facilitator .................................................................................................. 27
Learning Objectives ........................................................................................... 27
Target Participants ............................................................................................. 28
Expected Outcomes .......................................................................................... 28
Facilitator Notes ................................................................................................. 28
Equipment and Supplies ................................................................................... 28
Scenario Setup .................................................................................................... 29
Patient ............................................................................................................................................... 29
Room ................................................................................................................................................. 29
Scenario Commencement ................................................................................ 29
Handoff Report for Participants ............................................................................................... 29
Scenario Steps .................................................................................................... 30
Patient Response and Participant Actions .......................................................................... 30
Debrief ................................................................................................................... 32
Resources ............................................................................................................. 32
SENIOR CARE: FALL ASSESSMENT SCENARIO ............................. 35
Scenario Background ........................................................................................ 35
Information for the Facilitator .................................................................................................. 35
Learning Objectives ........................................................................................... 35
Target Participants ............................................................................................. 35
Expected Outcomes .......................................................................................... 36
Facilitator Notes ................................................................................................. 36
Equipment and Supplies ................................................................................... 36
Scenario Setup .................................................................................................... 37
Resident ............................................................................................................................................ 37
Room ................................................................................................................................................. 37
Scenario Commencement ................................................................................ 37
Handoff Report to Participants ................................................................................................ 37
Scenario Steps ..................................................................................................... 38
Resident Response and Participant Actions........................................................................ 38
Debrief ................................................................................................................... 39
Resources ............................................................................................................. 39
OBSTETRICS: SHOULDER DYSTOCIA SCENARIO .......................... 41
Scenario Background ......................................................................................... 41
Information for the Facilitator ................................................................................................... 41
Learning Objectives ............................................................................................ 41
Target Participants .............................................................................................. 41
Expected Outcomes .......................................................................................... 42
Facilitator Notes ................................................................................................. 42
Equipment and Supplies ................................................................................... 43
Scenario Setup ................................................................................................... 44
Patient .............................................................................................................................................. 44
Room ................................................................................................................................................ 44
Scenario Commencement ................................................................................ 45
Handoff Report to Participants ................................................................................................ 45
Scenario Steps ..................................................................................................... 45
Patient Response and Participant Actions ........................................................................... 45
Debrief .................................................................................................................. 46
Resources ............................................................................................................. 47
DENTAL PRACTICE: AGGRESSIVE PATIENT SCENARIO .............. 49
Scenario Background ....................................................................................... 49
Information for the Facilitator ................................................................................................. 49
Learning Objectives .......................................................................................... 49
Target Participants ............................................................................................ 49
Expected Outcomes ......................................................................................... 50
Facilitator Notes ................................................................................................ 50
Equipment and Supplies .................................................................................. 50
Scenario Setup ................................................................................................... 50
Patient .............................................................................................................................................. 50
Room .................................................................................................................................................. 51
Scenario Commencement ................................................................................. 51
Handoff Report for Participants ................................................................................................ 51
Scenario Steps ...................................................................................................... 51
Patient Response and Participant Actions ............................................................................ 51
Debrief ................................................................................................................... 52
Resources ............................................................................................................. 52
A N E S T H E S I A
Simulation Scenarios 1
ANESTHESIA: SURGICAL TEAM SCENARIO
The purpose of this scenario is to practice effective communication and efficient teamwork
skills, such as those defined in crew resource management programs and the Agency for
Healthcare Research and Quality’s (AHRQ’s) TeamSTEPPS
®
program. For more details, refer to
the “Facilitator Notes” on page 2.
This scenario is designed for an OR setting; however, the setting can be adjusted based on
individual facility practices.
Scenario Background
Information for the Facilitator
The patient is being admitted to the hospital because of end-
stage renal failure. Her past medical history is significant for
diabetes, hypertension, severe anemia, and suspected sepsis.
On admission, the patient’s BP is 150160/100.
During the admission, the patient receives dialysis on five
occasions. It is then determined that the access catheter needs
to be changed. An anesthesiologist evaluates the patient and
determines that she is ASA-IV. The patient is dialyzed prior to
the procedure.
At 1430, the anesthesiologist administers IV sedation with
midazolam 1 mg. Pulse oximetry and ECG monitoring are in
place. BP is 120/60 at 1430, 110/60 at 1435, and 100/60 at
1445. Normal saline is administered at 100 mL/hr. At 1450, the patient’s BP drops to 80/60. The
anesthesiologist administers atropine 0.5 mg. The surgeon replaces the catheter in 10 minutes.
At the end of the procedure, the patient becomes bradycardic (3040 beats per minute) and
then asystolic. The circulating nurse administers epinephrine 1 mg IV, the anesthesia provider
intubates the patient, and a code is called at 1456 (simultaneously).
Learning Objectives
During this scenario, participants will:
Recognize risks for complications and plan for appropriate monitoring
Provide appropriate and timely interventions (response to changes in physiological
status)
Exhibit proficient technical performance of interventions (code response)
Simulation Scenarios 2
Demonstrate effective communication with team members
Integrate resourceful teamwork in providing patient care
Target Participants
OR staff, surgeon(s), and anesthesia providers/staff
Expected Outcomes
Short-term: Implement effective communication and efficient teamwork concepts.
TeamSTEPPS-specific tools should include: brief, huddle, situation awareness, cross-
monitoring, CUS, and the two-challenge rule.
Long-term: Demonstrate improved patient outcomes for similar patient types.
Facilitator Notes
Below are tips to help the facilitator conduct the simulation.
Throughout this scenario, participants will be tasked with identifying opportunities to apply
effective communication and efficient teamwork skills, such as the ones recommended by
TeamSTEPPS. The tools and strategies specific to this scenario include: brief, huddle, situation
awareness, cross-monitoring, CUS, and the two-challenge rule. Visit AHRQ’s website for more
information about TeamSTEPPS.
Give each participant his/her own patient chart to
review. This enables him/her to obtain basic
information about the patient. However, prevent
discussion among members of the patient care
team prior to the administration of midazolam.
This puts the team members in a situation in
which no focus is on potential complications for
this highly compromised patient.
Again, the goal is to have patient care team members proactively initiate a discussion (brief)
prior to the procedure so that everyone is aware of what to look for (situation awareness)
and ready to assist each other in performing their tasks as needed (cross-monitoring).
Once a complication is recognized and shared with the team, and treatment efforts are initiated,
attention to the patient’s treatment response is paramount (situation awareness). When
information regarding complications isn’t shared and interventions aren’t effective to the level
desired, a team discussion about additional options (huddle) should take place. Continuing
with the initial procedure should elicit a response from team membersi.e., questioning or
stating concern about the patient’s safety (CUS and/or two-challenge rule).
NOTE
If you prefer not to use the TeamSTEPPS
tools, a description of what is expected
from the participants is provided. Simply
disregard the words in parentheses in the
paragraphs below.
Simulation Scenarios 3
It is recommended that participants perform this
scenario twice in the same training session so
that learning and re-enforcement of
communication and teamwork skills can be
applied to their clinical practice.
Throughout the scenario, the facilitator will need
to provide data for the patient’s vital signs (see
“Scenario Stepson page 5). The data should be
displayed on a card, paper, or placard located
near the actual monitor.
Additionally, to facilitate the time needed for
each scenario session, the facilitator has the
option to compress (speed up) time as needed.
Make the participants aware of the time by either
displaying the time in a visible location or stating
the time throughout the scenario.
Equipment and Supplies
Operating room bed and bed sheet
Cardiac monitor/anesthesia machine and pulse oximetry with displays demonstrating
patient’s hemodynamic baseline and subsequent decompensation
Endotracheal tube (ETT) with lubricant
ETT holder
Hemodialysis catheters (old one to be removed/new one to be inserted)
IV cannula, fluid, and tubing
Paper tape (to secure IV, dialysis catheter, and IV cannula)
Scrub gowns, scrub caps, and shoe covers
Surgical procedure supplies (sterile field, drapes, etc.)
Syringes labeled midazolam, atropine, and epinephrine
Telephone
DEFINITIONS
CUS is a tool to use when a conflict of
information is identified that warrants a
team member voicing his/her Concern,
that he/she is Uncomfortable, and a
Safety issue exists. Each facility or
practice may develop a unique word,
phrase, or signal to alert the other
team members without alarming the
patient/family.
The two-challenge rule is a tool to
use when a conflict of information is
identified that warrants a team member
speaking up, alerting, and/or
questioning other team members at
least twice before proceeding any
further with a task or intervention.
Simulation Scenarios 4
Scenario Setup
Patient
Hospital gown and slipper socks (for the actor)
Hemodialysis catheter (secure to the patient’s upper
right chest; current catheter to be removed)
IV cannula (secure to either of the patient’s forearms)
IV fluid with tubing (connect to the IV cannula)
Room
Place bed sheet on the bed
Position patient (actor with airway task trainer or simulator) on the bed
Assemble sterile surgical table with new hemodialysis catheter, syringes, and procedural
instruments, as needed
Position sterile surgical table near the bed
Position cardiac monitor/anesthesia machine at the head of the bed
Connect cardiac monitor/anesthesia machine leads and pulse oximetry to patient
Scenario Commencement
Handoff Report for Participants
The patient is being admitted to the hospital because of end-stage renal failure. Her past
medical history is significant for diabetes, hypertension, severe anemia, and suspected sepsis.
On admission, the patient’s BP is 150160/100.
During the admission, the patient receives dialysis
on five occasions. It is then determined that the
access catheter needs to be changed.
An anesthesiologist evaluates the patient and
determines that she is ASA-IV. The patient is
dialyzed prior to the procedure.
NOTE
An actor along with a
separate airway task trainer
or simulator with ETT
capability can be used.
NOTE
Provide the handoff information in
patient chart form only. Discourage
verbal discussion prior to the start of
the scenario (see the “Facilitator
Notes” on page 2).
Simulation Scenarios 5
Scenario Steps
Patient Response and Participant Actions
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
1430 BP: 120/60
Cardiac rhythm:
normal sinus
Patient status and concerns
discussed with team
members
Anesthesiologist administers
midazolam 1 mg IV
Patient status and concerns
discussed with team members
(brief) prior to midazolam
administration?
Yes No
1435 BP: 110/60
Anesthesiologist alerts the
team about the patient’s
decreasing BP
Information about decreasing
BP communicated?
Yes No
1445 BP: 100/60 Anesthesiologist alerts the
team about the patient’s
decreasing BP
Anesthesiologist leads a
quick discussion about
potential emergency
interventions
Anesthesiologist infuses
normal saline 100 ml/hr
Team members alerted about
the patient’s decreasing BP
(situation awareness/
cross-monitoring)?
Yes No
Quick discussion about
potential emergency
interventions conducted
(huddle)?
Yes No
1450 BP: 80/60 Anesthesiologist discusses
concern regarding patient
status and continuing with
procedure
Anesthesiologist administers
atropine 0.5 mg IV
Discussion conducted about
patient status and continuing
with procedure (CUS and/or
two-challenge rule)?
Yes No
Simulation Scenarios 6
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
1455 Heart rate:
3040 BPM
Cardiac rhythm:
bradycardia
Surgeon completes new
catheter placement
N/A
1456 Heart rate: N/A
Cardiac rhythm:
asystole
Epinephrine 1 mg IV
administered, ETT inserted,
and code called
Timely CPR initiated?
Yes No
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
What did you think was happening?
What did you do and why?
Do you think your interventions were helpful? Describe how. If not, explain why.
Did the team members communicate effectively with each other? Provide examples.
Did the team members communicate effectively with the patient? Provide examples.
How efficient was the teamwork? Provide examples.
What aspects of this scenario exercise can you apply to your clinical practice? How might
you apply those aspects?
Resources
Agency for Healthcare Research and Quality: TeamSTEPPS
B E H A V I O R A L
H E A L T H
Simulation Scenarios 9
BEHAVIORAL HEALTH: DE-ESCALATION SCENARIO
The purpose of this scenario is for participants to recognize early signs and symptoms of a
potential behavioral crisis. De-escalation techniques should be performed to assist the patient in
maintaining safety and appropriate behaviors. For more details, refer to the “Facilitator Notes”
on page 10.
This scenario is written for an inpatient setting; however, it can be reconfigured for an
emergency department scenario.
Scenario Background
Information for the Facilitator
At the time of admission, the patient’s principal
diagnosis is paranoid schizophrenia with a
secondary diagnosis of paranoid personality
disorder. The admission record notes a history of
nonadherence, a past suicide attempt, and a
several-month history of refusal to eat, decreased
sleep, and social isolation. The patient’s Global
Assessment of Functioning score is 28.
Further assessment reveals that the patient
believes people are conspiring against him, dogs
talk to him, and the television sends him messages. The patient exhibits irritable and anxious
behavior. Psychiatrist assessment reveals the patient has suicidal ideations and that his
judgment is grossly impaired.
The patient appears disheveled, disorganized, suspicious, delusional, and paranoid. He refuses
voluntary treatment. Intense supervision until further stabilization is warranted, and the process
of inpatient involuntary commitment is completed. During Day 1 of admission, while in his
room, the patient becomes increasingly agitated. He begins to throw furniture and threatens
others who he believes are conspiring against him.
Learning Objectives
During this scenario, participants will:
Recognize a potentially volatile situation (risks of escalation)
Provide appropriate and timely interventions (de-escalation techniques)
Demonstrate effective communication with the patient and team members
Integrate resourceful teamwork in providing patient care
Simulation Scenarios 10
Target Participants
Behavioral health staff
Expected Outcomes
Short-term: Apply appropriate de-escalation techniques to avoid patient and staff harm
and to safely resolve the crisis.
Long-term: Recognize early signs of an escalating crisis and promptly notify staff.
Facilitator Notes
Below are tips to help the facilitator conduct the simulation.
Because communication and behavioral assessment are the main objectives of the scenario, a
standardized patient (SP) actor can best fill the role of the patient. Provide scripting and general
behavior guidelines to the SP prior to the simulation session so that he can deliver appropriate
responses to the participants.
Times listed under “Scenario Steps” serve as a guide only. Depending on the participants, the
time for this scenario might need to be shortened or extended.
Equipment and Supplies
Hospital bed and bed sheet
Two kitchen-type/cafeteria-type chairs
Small table
Telephone
Scenario Setup
Patient
Street clothes
Room
Place bed sheet on bed
Position patient (actor) in the room
Scenario Commencement
Handoff Report for Participants
The patient was admitted with a primary diagnosis of paranoid schizophrenia and a secondary
diagnosis of paranoid personality disorder. He has a history of nonadherence, a past suicide
attempt, and a several-month history of refusing to eat, decreased sleep, and social isolation.
Simulation Scenarios 11
In addition, he believes people are conspiring against him, dogs talk to him, and the television
sends him messages.
The patient exhibits irritable and anxious behavior, and he has suicidal ideations and grossly
impaired judgment. His Global Assessment of Functioning score is 28. The patient has refused
voluntary treatment. In the meantime, he requires intense supervision until the process of
inpatient involuntary commitment is completed. He appears disheveled, disorganized,
suspicious, delusional, and paranoid.
Scenario Steps
Patient Response and Participant Actions
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
0100 Appearance:
disheveled
Behavior:
Irritable, anxious,
suspicious,
delusional, and
paranoid
Perform assessment of
patient
Appropriate assessment
completed?
Yes No
0102 Behavior:
Increasing
irritability and
anxiousness
Apply appropriate
de-escalation techniques
Appropriate de-escalation
techniques applied?
Yes No
0103 Behavior: Begins
acting out by
throwing furniture
Continue with de-escalation
techniques and notify
coworkers
De-escalation techniques
continued?
Yes No
Coworkers notified?
Yes No
0105 Behavior:
Irritability and
anxiousness
decrease
Engage in appropriate
communication with patient
Appropriate communication
occurred?
Yes No
Simulation Scenarios 12
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
What did you think was happening?
What did you do and why?
Do you think your interventions were helpful? Describe how. If not, explain why.
Did the team members communicate effectively with each other? Provide examples.
Did the team members communicate effectively with the patient? Provide examples.
How was safety addressed and maintained throughout the scenario (e.g., notified
response team, maintained eye contact with the patient, positioned yourself between the
patient and the exit door, demonstrated a calm but firm tone, and exhibited
nonthreatening body language)?
What aspects of this scenario exercise can you apply to your clinical practice? How might
you apply those aspects?
Resources
Crisis Prevention Institute: Create a Culture of Safety: How to Reduce Intimidation and
Violence in Health Care Facilities (Webinar)
Crisis Prevention Institute: From Chaos to Calm: How to Create a Safe and Caring
Hospital (Webinar)
Western Journal of Emergency Medicine:
Verbal De-escalation of the Agitated Patient:
Consensus Statement of the American Association for Emergency Psychiatry Project BETA
De-escalation Workgroup
E M E R G E N C Y
M E D I C I N E
Simulation Scenarios 15
EMERGENCY MEDICINE: PEDIATRIC PATIENT SCENARIO
The purpose of this scenario is to practice (a) assessment and care for a pediatric patient in
respiratory distress, and (b) effective communication and efficient teamwork skills, such as
those defined in crew resource management programs and the Agency for Healthcare Research
and Quality’s (AHRQ’s) TeamSTEPPS
®
program. For more details, refer to the “Facilitator Notes”
on page 16.
An infant simulator with endotracheal tube (ETT) intubation capability should be used to
practice ETT intubation during this scenario. If your organization does not have one, contact
your local emergency medical services (EMS) provider to see whether it has an infant simulator
available for use. Other options for securing an infant simulator include your organization’s
foundation society and healthcare/patient safety grants through state and federal programs.
Scenario Background
Information for the Facilitator
A 4-month-old male patient was transported from
home by his parents to the emergency department
(ED). The patient has had an upper respiratory
infection over the past 24 hours with a moist
cough and runny nose. Within the past few hours,
the patient has become febrile, listless, and has
audible rhonchi.
The parents and the patient are immediately
escorted to an exam room upon arrival at the
hospital. The baby has slight circumoral cyanosis,
flaring nostrils, and chest retractions. Upon arrival, the baby’s vital signs are BP 74/palp,
pulse 110, respirations 34 and shallow, and temperature 39.5°C (103.1°F). The baby becomes
unresponsive as providers are administering care to him.
Learning Objectives
During this scenario, participants will:
Recognize risks for complications and plan for appropriate monitoring
Provide appropriate and timely interventions (response to changes in physiological
status)
Exhibit proficient technical performance of interventions
Demonstrate effective communication with team members
Integrate resourceful teamwork in providing patient care
Simulation Scenarios 16
Target Participants
ED staff, physician(s), anesthesia providers, and respiratory therapy staff
Expected Outcomes
Short-term: Identify multiple opportunities for hands-on drill training in the ED setting.
Implement effective communication and teamwork skills, such as the following
TeamSTEPPS tools: leadership, brief, check-back (closed-loop communication), huddle,
situation awareness, and mutual support.
Long-term: Implement a simulation training program for the ED that encompasses a
variety of clinical and behavioral situations so that staff are better prepared, and supplies
and equipment are readily available for actual events.
Facilitator Notes
Below are tips to help the facilitator conduct the simulation.
Throughout this scenario, participants will be tasked with quickly assessing and determining
appropriate treatment for an infant in respiratory distress. Additionally, participants will be
asked to identify opportunities to apply effective communication and efficient teamwork skills,
such as the ones recommended by TeamSTEPPS.
The tools and strategies specific to this scenario
include: leadership, brief, closed-loop
communication, huddle, situation awareness, and
mutual support. Visit AHRQ’s website for more
information about TeamSTEPPS.
During the critical patient event, participants
should establish a leader (leadership) to
delegate tasks and coordinate the team’s efforts in caring for the patient. Prior to initiating
interventions, the team leader should discuss the patient’s status and plan of care with the team
members (brief).
To avoid delays in, duplications of, or deviations in tasks, team members should restate the
team leader’s instructions (check-back). At some point during the emergency response, team
members should review all tasks that have been done to confirm that nothing was forgotten
and to determine other courses of action (huddle).
To prevent any patient mishaps, it is essential that all team members continually observe the
ongoing event (situation monitoring) and provide necessary feedback and assistance
(mutual support) to the team particularly when performing CPR, as responder fatigue can
occur quickly.
NOTE
If you prefer not to use the TeamSTEPPS
tools, a description of what is expected
from the participants is provided. Simply
disregard the words in parentheses in the
paragraphs below.
Simulation Scenarios 17
It is recommended that participants perform this scenario twice in the same training session so
that learning and re-enforcement of communication and teamwork skills can be applied to their
clinical practice.
Throughout the scenario, the facilitator will need to provide data for the patient’s vital signs
(see “Scenario Steps” on page 18). The data should be displayed on a card, paper, or placard
located near the actual monitor.
Additionally, to facilitate the time needed for each scenario session, the facilitator has the option
to compress (speed up) time as needed. Make the participants aware of the time by either
displaying the time in a visible location or stating the time throughout the scenario.
Equipment and Supplies
ED bed/stretcher and bed sheet
Cardiac monitor with pulse oximetry
IV fluid, tubing, and cannula (infant)
Paper tape (to secure IV and IV cannula)
Syringes labeled epinephrine and amiodarone
Pediatric ETT with lubricant and ETT holder
Telephone or other communication device
Scenario Setup
Patient
Street clothing
Room
Place bed sheet on bed
Position patient (simulator) on bed
Scenario Commencement
Handoff Report for Participants
A 4-month-old male patient was transported from home by his parents to the ED. The patient
has had an upper respiratory infection over the past 24 hours with a moist cough and runny
nose. Within the past few hours, the patient has become febrile, listless, and has audible
rhonchi. The parents and the patient are immediately escorted to an exam room upon arrival at
the hospital. The baby has slight circumoral cyanosis, flaring nostrils, and chest retractions.
Upon arrival, the baby’s vital signs are BP 74/palp, pulse 110, respirations 34 and shallow, and
temperature 39.5°C (103.1°F).
NOTE
If possible, use an actual ED
room. This setup will be most
beneficial during the scenario.
Simulation Scenarios 18
Scenario Steps
Patient Response and Participant Actions
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
1900 BP: 74/palp
Pulse: 110
Respirations:
34/shallow
Temperature:
39.5°C
(103.1°F)
Participants establish a team
leader
Team leader discusses
patient status and concerns
with team members
Team leader established
(leadership)?
Yes No
Patient status and concerns
discussed with team members
(brief)?
Yes No
1905 BP: 70/palp
Pulse: 110
Respirations:
36/shallow
Tasks are delegated to and
confirmed by all team
members
Effective communication
performed (check-back)?
Yes No
1907 BP: 68/palp
Pulse: 110
Respirations:
36/shallow
Team members actively
monitor the event and
provide feedback as needed
Team leader reviews which
tasks have been completed
and asks for team member
input
Event monitored and feedback
provided (situation
awareness)?
Yes No
Review of tasks performed and
feedback requested (huddle)?
Yes No
1910 BP: 0
Pulse: 0
Respirations: 0
Team members assist in task
performance
Assistance in task performance
occurs (mutual support)?
Yes No
Simulation Scenarios 19
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
What did you think was happening?
What did you do and why?
Do you think your interventions were helpful? Describe how. If not, explain why.
Did the team members communicate effectively with each other? Provide examples.
Did the team members communicate effectively with the patient’s parents? Provide
examples.
How efficient was the teamwork? Provide examples.
What aspects of this scenario exercise can you apply to your clinical practice? How might
you apply those aspects?
Resources
Agency for Healthcare Research and Quality: TeamSTEPPS
H E A L T H C A R E
P R A C T I C E
Simulation Scenarios 21
HEALTHCARE PRACTICE: EMERGENCY SCENARIO
The purpose of this scenario is to (a) assess the healthcare practice’s emergency preparedness
for an unresponsive patient, and (b) to apply effective communication and efficient teamwork
skills, such as those defined in crew resource management programs and the Agency for
Healthcare Research and Quality’s (AHRQ’s) TeamSTEPPS
®
program. For more details, refer to
the “Facilitator Notes” on page 22.
This scenario is written for the primary care setting; however, it can be reconfigured for other
specialty settings.
Scenario Background
Information for the Facilitator
A young adult male presents to the healthcare
practice with chronic cough from seasonal
allergies and a complaint of chest discomfort.
Because of the patient’s age and history of
allergies, he is diagnosed with sore chest wall
muscles.
A family history significant for heart disease is
indicated on the intake form, but it is not taken
into consideration.
Two days later, the patient returns to the practice
for a follow-up visit for worsening chest discomfort. While waiting, the patient suddenly falls to
the floor and becomes unresponsive.
Learning Objectives
During this scenario, participants will:
Recognize signs and symptoms of a medical emergency and plan for care
Provide appropriate and timely interventions
Exhibit proficient technical performance of interventions
Demonstrate effective communication with team members
Integrate resourceful teamwork in providing patient care
Target Participants
Healthcare providers and office staff
Simulation Scenarios 22
Expected Outcomes
Short-term: Recognize the importance of conducting and participating in a variety of
emergency drills throughout the year to enhance provider/staff knowledge and
proficiency.
Long-term: Implement an emergency preparedness program that includes periodic
practice drills to ensure timely response and optimal patient outcomes.
Facilitator Notes
Below are tips to help the facilitator conduct the simulation.
Throughout this scenario, participants will be tasked with providing primary emergency
response for a critically ill patient and identifying opportunities to apply effective communication
and efficient teamwork skills, such as the ones
recommended by TeamSTEPPS. The tools and
strategies specific to this scenario include:
leadership, brief, check-back (closed-loop
communication), mutual support, communication,
and situation monitoring. Visit AHRQ’s website for
more information about TeamSTEPPS.
Prepare a patient chart for participants based on
the patient information provided in the “Scenario Background” on page 21. The patient should
be 2030 years old. The facilitator can determine the patient’s ethnic and social history.
During the medical emergency, participants should establish a leader (leadership) to delegate
tasks and coordinate the team’s efforts in caring for the patient. Prior to initiating interventions,
the team leader should discuss the patient’s status and plan of care with the team members
(brief). To avoid delays in, duplications of, or deviations in tasks, team members should restate
the team leader’s instructions (check-back).
Effective discussions (communication) among all team members will promote timely
execution of interventions and team awareness of all steps being performed, such as the
number of CPR cycles, cardiac rhythm assessment, and safety precautions during defibrillations.
Team members should continually observe the ongoing event (situation monitoring) and
provide necessary assistance and guidance (mutual support) to the teamparticularly when
performing chest compressions, as responder fatigue can occur quickly.
It is recommended that participants perform this scenario twice in the same training session so
that learning and re-enforcement of communication and teamwork skills can be applied to their
clinical practice. Additionally, running the scenario twice might help participants identify ways in
which they can more successfully execute their responses.
NOTE
If you prefer not to use the TeamSTEPPS
tools, a description of what is expected
from the participants is provided. Simply
disregard the words in parentheses in the
paragraphs below.
Simulation Scenarios 23
Throughout the scenario, the facilitator will need to provide data for the patient’s vital signs
and cardiac rhythms (see “Scenario Steps” on page 24). The data should be displayed on a
card, paper, or placard located near the equipment being used. If an actual monitor is being
used, program the cardiac rhythm and other parameters according to the data indicated in the
“Scenario Steps.” If participants are using an actual monitor and/or defibrillator for the scenario,
ensure safety precautions are followed when the equipment is in use.
Additionally, to facilitate the time needed for each scenario session, the facilitator has the option
to compress (speed up) time as needed. Make the participants aware of the time by either
displaying the time in a visible location or stating the time throughout the scenario.
Equipment and Supplies
Telephone
Timepieces (wall clocks, etc.)
BLS/ACLS supplies, if appropriate to setting (portable oxygen with flow meter, adult bag-
valve-mask)
AED (if none available, note during debrief)
Notepad for recording response and intervention
Scenario Setup
Patient
Street clothes
Room
Position patient on the floor in the waiting area
Obtain equipment from normal storage place at time of simulation response
Scenario Commencement
Handoff Report for Participants
A young adult male presents to the healthcare practice with chronic cough from seasonal
allergies and a complaint of chest discomfort. Because of the patient’s age and history of
allergies, he is diagnosed with sore chest wall muscles. A family history significant for heart
disease is indicated on the intake form, but it is not taken into consideration.
Two days later, the patient returns to the practice for a follow-up visit for worsening chest
discomfort. While waiting, the patient suddenly falls to the floor and becomes unresponsive.
Simulation Scenarios 24
Scenario Steps
Patient Response and Participant Actions
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
0900 BP: 0
Pulse: 0
Respirations: 0
Participants recognize
patient unresponsiveness
and notify office team
Team members alerted to
unresponsive patient?
Yes No
0903 Same as above Team members establish a
team leader
Team leader discusses
patient status and
concerns with team
members
Team leader established
(leadership)?
Yes No
Patient status and concerns
discussed with team
members (brief)?
Yes No
0905 Same as above
Tasks are delegated to and
confirmed by all team
members
Team members
communicate effectively
about patient status,
notifications (e.g., EMS,
office support), and task
performance
Effective communication
performed (check-back)?
Yes No
Verbal interaction
(communication) with
team is effective?
Yes No
0907 Same as above Team members monitor
the patient’s response and
team performance
Monitoring of patient
response and team
performance conducted
(situation monitoring)?
Yes No
Simulation Scenarios 25
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
0910 Same as above Team members assist in
task performance
Assistance in tasks
performance occurs (mutual
support)?
Yes No
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
What did you think was happening?
What did you do and why?
What was the timeline between initial recognition of the
patient’s unresponsiveness and interventions (i.e.,
initiating BLS/ACLS, calling 911, using the AED, and
providing oxygen using a bag-valve-mask)?
Do you think your interventions were helpful? Describe
how. If not, explain why.
Did the team members communicate effectively with
each other? Provide examples.
How efficient was the teamwork? Provide examples.
What aspects of this scenario exercise can you apply to your clinical practice and
workplace protocols? How might you apply those aspects?
Resources
American Academy of Family Physicians: A Practical Guide to Emergency Preparedness
for Office-Based Family Physicians
American Academy of Pediatrics: Pediatric Preparedness Resource Kit
NOTE
A discussion should take
place with regards to the
timeframe from when the
patient initially became
unresponsive until the time
when EMS or other
emergency care responders
would likely arrive.
M E D I C A L -
S U R G I C A L
N U R S I N G
Simulation Scenarios 27
MEDICAL-SURGICAL NURSING: SEPSIS SCENARIO
The purpose of this scenario is to have participants recognize early signs and symptoms of
sepsis and to initiate the elements of a sepsis bundle. In addition, the participants should be
prepared to notify the emergency response team and demonstrate BLS skills. For more
details, refer to the “Facilitator Notes” on page 28.
Scenario Background
Information for the Facilitator
Earlier in the day, a female patient weighing
132 pounds (60 kg) underwent a laparoscopic
right hemicolectomy for newly diagnosed
colon cancer. The surgery was reported to be
without complications.
The patient has been on the medical-surgical
nursing unit for the past 4 hours. Currently the
patient is stable, has no complaints of pain,
and has the following vital signs: BP 112/74,
pulse 88, respirations 14, and temperature
37°C (98.6°F).
The patient is on intake and output monitoring with a Foley catheter in place and draining clear
yellow urine. The patient is to remain NPO for the next 24 hours. A 20-gauge IV catheter has
been placed in the patient’s right forearm with normal saline infusing at 150 mL/hour.
IV antibiotics are ordered for the patient cefazolin 1 gram every 6 hours and metronidazole
500 mg every 6 hours. Neither antibiotic has been given at this time because of a pharmacy
delay. The patient was given hydromorphone 0.4 mg IV 30 minutes ago, and an order is in
place for her to receive 0.4 mg every 12 hours, as needed.
Within 4 hours of surgery, the patient’s abdomen becomes distended and tender, her urine
output is 15 mL/hour, and her white blood cell count increases from 5.8 immediately after
surgery to 8.2. Her other vital signs are: BP 82/52, pulse 130, and respirations 37. Lactic acid is
3.6 mmol/L. The patient is taken back to surgery where a duodenal perforation is discovered.
Learning Objectives
During this scenario, participants will:
Recognize risks for complications and plan for appropriate monitoring
Provide proper and timely interventions (response to changes in physiological status)
Simulation Scenarios 28
Exhibit proficient technical performance of interventions
Demonstrate effective communication with team members
Integrate resourceful teamwork in providing patient care
Target Participants
Medical-surgical nurses and staff
Expected Outcomes
Short-term: Recognize early signs and symptoms of sepsis and quickly implement a
sepsis bundle.
Long-term: Demonstrate improved patient outcomes for similar patient types.
Facilitator Notes
Below are tips to help the facilitator conduct the simulation.
A standardized patient (SP) actor can be used for much of this scenario. A BLS manikin will be
needed at the point when the patient becomes unresponsive so that participants can practice
CPR skills. If a high-fidelity simulator is available, the team can use it for the entire scenario.
In conducting this scenario, the facilitator needs to ensure that the appropriate organizational
process for initiating a sepsis bundle is followed. For example, if the sepsis bundle is a
standardized order set that nursing can initiate without a physician or advanced practice
provider (APP) order, then participants should demonstrate that course of action during the
scenario. However, if a physician or APP must initiate all patient orders, then the facilitator must
have the physician or APP state the order for the bundle elements.
It is recommended that participants perform this scenario twice in the same training session so
that learning and re-enforcement of the sepsis bundle elements and BLS skills can be applied to
their clinical practice.
Throughout the scenario, the facilitator will need to provide data for vital signs. The data should
be displayed on a card, paper, or placard located near the actual monitor.
Additionally, to facilitate the time needed for each scenario session, the facilitator has the option
to compress (speed up) time as needed. Make the participants aware of the time by either
displaying the time in a visible location or stating the time throughout the scenario.
Equipment and Supplies
Patient bed and bed sheet
Monitors (pulse oximeter and BP)
Simulation Scenarios 29
IV fluid (normal saline), tubing, and cannula
Gloves
Telephone
Clock
Phlebotomy supplies (blood culture and lactate)
Scenario Setup
Patient
Hospital gown and slipper socks (for the actor)
IV cannula (secure to the patient’s forearm)
IV fluid with tubing (connect to the cannula)
BP device/monitor
Pulse oximetry device/monitor
Room
Place bed sheet on bed
Position patient on bed
Scenario Commencement
Handoff Report for Participants
Earlier in the day, a female patient weighing 132 pounds (60 kg) underwent a laparoscopic right
hemicolectomy for newly diagnosed colon cancer. The surgery was reported to be without
complications. The patient has been on the medical-surgical nursing unit for the past 4 hours.
Currently the patient is stable, has no complaints of pain, and has the following vital signs:
BP 112/74, pulse 88, respirations 14, and temperature 37°C (98.6°F).
The patient is on intake and output monitoring with a Foley catheter in place and draining clear
yellow urine. The patient is to remain NPO for the next 24 hours. A 20-gauge IV catheter has
been placed in the patient’s right forearm with normal saline infusing at 150 mL/hour.
IV antibiotics are ordered for the patient cefazolin 1 gram every 6 hours and metronidazole
500 mg every 6 hours. Neither antibiotic has been given at this time because of a pharmacy
delay. The patient was given hydromorphone 0.4 mg IV 30 minutes ago, and an order is in
place for her to receive 0.4 mg every 12 hours, as needed.
Simulation Scenarios 30
Scenario Steps
Patient Response and Participant Actions
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
1500 BP: 112/74
Pulse: 88
SpO
2
: 99% on 4L NC
Respirations: 14
Temperature: 37°C
(98.6°F)
Pain: 0 out of 10
Assess the patient Patient assessment done?
Yes No
1510 BP: 88/62
Pulse: 98
SpO
2
: 95% on 4L NC
Respirations: 18
Temperature: 37°C
(98.6°F)
Abdominal pain:
6 out of 10
Assess the patient
Consider possible causes
for pain and changes in
vital signs
Notify physician (see
“Facilitator Notes” on
page 28)
Patient assessment done?
Yes No
Possible causes considered?
Yes No
Physician notified?
Yes No
1512 BP: 88/62
Pulse: 98
SpO
2
: 95% on 4L NC
Respirations: 18
Temperature: 37°C
(98.6°F)
Abdominal pain:
6 out of 10
Activate sepsis bundle
Collect blood cultures
prior to antibiotic
administration
Obtain lactate level
Increase IV normal saline
infusion (30 mL/kg x
60 kg = 1,800 mL/hr)
Sepsis bundle activated?
Yes No
Blood cultures collected?
Yes No
Lactate level obtained?
Yes No
Saline infusion increased?
Yes No
Simulation Scenarios 31
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
1515 BP: 84/58
Pulse: 122
SpO
2
: 92% on 4L NC
Respirations:
30/shallow
Temperature: 37.2°C
(98.6°F)
Abdominal pain:
9 out of 10
Call for assistance
Activate Emergency
Response Team
Clear the room
Retrieve crash cart
Move head of bed away
from wall
Place defibrillator leads
on patient
Assistance called?
Yes No
Emergency Response Team
notified?
Yes No
Room cleared?
Yes No
Crash cart retrieved?
Yes No
Bed moved away from the
wall?
Yes No
Defibrillator leads placed on
patient?
Yes No
1518 Patient unresponsive;
no vital signs
detected
Begin CPR
Defibrillate patient as
needed
CPR initiated?
Yes No
Defibrillation provided as
needed?
Yes No
Simulation Scenarios 32
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
What did you think was happening?
What did you do and why?
Do you think your interventions were helpful? Describe how. If not, explain why.
Did the team members communicate effectively with each other? Provide examples.
Did the team members communicate effectively with the patient? Provide examples.
How efficient was the teamwork? Provide examples.
What aspects of this scenario exercise can you apply to your clinical practice? How might
you apply those aspects?
Resources
Surviving Sepsis Campaign: Updated Bundles in Response to New Evidence
S E N I O R
C A R E
Simulation Scenarios 35
SENIOR CARE: FALL ASSESSMENT SCENARIO
The purpose of this scenario is to have participants conduct a fall assessment and to recognize
potential fall risks in order to initiate the appropriate fall prevention measures based on
organizational protocols. For more details, refer to the “Facilitator Notes” on page 36.
Scenario Background
Information for the Facilitator
A 78-year-old male is being admitted to a senior care rehabilitation
and nursing center following a 3-week admission in intensive care
at a nearby hospital; the admission was for bilateral lung
pneumonia. The resident is stable, alert, and oriented, but he has
overall muscle fatigue from his lengthy hospital stay.
The plan is to have the resident regain his ability to perform
activities of daily living prior to discharge home. He lives alone, but
has two adult children who live several miles away. He has a past
medical history of atrial fibrillation, hypertension, and
osteoarthritis. His current medications include lisinopril 5 mg daily,
hydrochlorothiazide 12.5 mg daily, warfarin 4 mg daily, and
celecoxib 200 mg daily.
The resident’s last INR was 2.5, which was done yesterday. He is
on portable oxygen at 2 L/min via nasal cannula. The resident has urinary urgency but is not
incontinent. His gait is slow and shuffling. His arthritis pain is well managed with celecoxib.
Learning Objectives
During this scenario, participants will:
Recognize risks for resident falls
Perform a thorough fall assessment on a resident
Initiate appropriate fall prevention precautions based on the assessment
Demonstrate effective communication with the resident
Document assessment findings, fall precaution measures initiated, and communication
with the resident
Provide a complete resident handoff report to a team member taking over resident care
Target Participants
Senior care nurses and nursing assistant staff
Simulation Scenarios 36
Expected Outcomes
Short-term: Recognize potential risks for resident falls, perform a thorough fall
assessment on a resident, and initiate appropriate fall precaution measures.
Long-term: Reduce resident falls within the organization.
Facilitator Notes
Below are tips to help the facilitator conduct the simulation.
A standardized patient (SP) actor should be used for the scenario. The facilitator should provide
the resident background to the SP well in advance of conducting the scenario so that the SP can
respond appropriately to the participant’s questions.
In conducting this scenario, the facilitator needs to ensure that the appropriate organizational
process for fall assessment is followed. The assessment should include review of medical
history, vital signs, pain, bladder and bowel function (including urgency), gait, cognition,
medications and supplements, psychosocial behavior, compliance with prescribed care, and
smoking status.
The facilitator should have the organization’s fall assessment plan available throughout the
scenario. The plan should be reviewed during the debrief with the participants.
Throughout the scenario, the facilitator will need to provide data for vital signs. The data should
be displayed on a card, paper, or placard located near the actual monitor. All other resident-
specific responses should be provided by the SP.
As part of the resident education step in the scenario, the teach-back method is indicated. To
access the teach-back toolkit, click on the link found in the “Resources section on page 39.
If you prefer to not use the teach-back method, simply disregard the words in parentheses in
“Scenario Steps.”
Equipment and Supplies
Resident bed and bed sheet
Portable oxygen tank in holder
Nasal cannula, extra oxygen tubing, and connector (if desired)
Thermometer
BP and pulse oximetry monitors
Gloves
Chair
Simulation Scenarios 37
Scenario Setup
Resident
Street clothes
Nasal cannula (place cannula on the resident and attach the other end to the oxygen
tank set at 2 L/min)
Room
Position resident on the bed or in the chair with oxygen tank and nasal cannula in place,
as indicated above
Assemble vital sign equipment in the room
Scenario Commencement
Handoff Report to Participants
A 78-year-old male is being admitted to a senior care rehabilitation and nursing center following
a 3-week admission in intensive care at a nearby hospital; the admission was for bilateral lung
pneumonia. The resident is stable, alert, and oriented, but he has overall muscle fatigue from
his lengthy hospital stay.
The plan is to have the resident regain his ability to perform activities of daily living prior to
discharge home. He lives alone, but has two adult children who live several miles away. He has
a past medical history of atrial fibrillation, hypertension, and osteoarthritis. His current
medications include lisinopril 5 mg daily, hydrochlorothiazide 12.5 mg daily, warfarin 4 mg daily,
and celecoxib 200 mg daily.
The resident’s last INR was 2.5, which was done yesterday. He is on portable oxygen at 2 L/min
via nasal cannula. The resident has urinary urgency but is not incontinent. His gait is slow and
shuffling. His arthritis pain is well managed with celecoxib.
Simulation Scenarios 38
Scenario Steps
Resident Response and Participant Actions
RESIDENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
BP: 128/72
Pulse: 92
Respirations: 14
SpO
2
: 98% on 2L NC
Temperature: 37°C
(98.6°F)
Pain: 0 out of 10
Lungs: clear
Continent of bladder
and bowel
Assess the resident for medical
history, vital signs, pain,
bladder and bowel function
(including urgency), gait,
cognition, medications and
supplements, psychosocial
behavior, care compliance, and
smoking
Resident assessment performed?
Yes No
Same as above Initiate fall prevention
precautions
Appropriate fall prevention
precautions initiated?
Yes No
Same as above Discuss care and educate
resident
Confirm resident’s
understanding of his care plan
and fall prevention measures
Effective communication
occurred?
Yes No
Resident understanding confirmed
(teach-back)?
Yes No
Same as above Provide thorough
documentation of the fall
assessment
All parameters of the fall
assessment accurately
documented?
Yes No
Simulation Scenarios 39
RESIDENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
Same as above Provide complete resident
handoff report including,
medical history, vital signs,
pain, bladder and bowel
function (including urgency),
gait, cognition, medications
and supplements, psychosocial
behavior, care compliance,
smoking, lung sounds, and
demeanor
Complete resident handoff report
communicated?
Yes No
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
How do you think you did in assessing the resident?
What aspects of your assessment did you consider when initiating fall prevention
precautions?
Do you think the fall prevention precautions will be effective? If yes, describe how. If not,
explain why.
Did you communicate effectively with the resident? Provide examples.
Did you provide appropriate handoff information to your team member? Provide
examples.
What aspects of this scenario exercise can you apply to your clinical practice? How might
you apply those aspects?
Resources
Center for Geriatric Clinical Simulation at the University of North Carolina at Chapel Hill
Always Use Teach-back!
O B S T E T R I C S
Simulation Scenarios 41
OBSTETRICS: SHOULDER DYSTOCIA SCENARIO
The purpose of this scenario is to practice effective communication and efficient teamwork
skills, such as those defined in crew resource management programs and the Agency for
Healthcare Research and Quality’s (AHRQ’s) TeamSTEPPS
®
program. For more details, refer to
the “Facilitator Notes” on page 42.
Scenario Background
Information for the Facilitator
A laboring patient (G2P1) was admitted at 39 weeks
gestation to Labor & Delivery (L&D) by an on-call
obstetrician from an OB clinic. The patient’s previous
medical history includes a pregnancy in her teens
and anemia. Ultrasounds during prenatal care at the
clinic were normal. Records indicate a 49-pound
weight gain throughout the pregnancy.
Upon assessment, the patient is approximately 4 cm
dilated with membranes ruptured and mild vaginal
bleeding noted. Baseline FHR is in the 140s without
decelerations. The fetal weight is estimated at
8.5 pounds (more likely 10 pounds).
Labor progresses for 12 hours without any change in cervical dilation. Oxytocin augmentation is
initiated, but the wrong dosing is ordered. Once the patient is fully dilated and pushing, the
obstetrician delivers the head and encounters shoulder dystocia (SD).
Learning Objectives
During this scenario, participants will:
Recognize risks for SD and plan for potential complications
Provide appropriate and timely interventions
Question physician orders for improper medication administration
Demonstrate effective communication with the patient, patient’s partner, and team
members
Integrate resourceful teamwork in providing patient care
Target Participants
OB providers and OB nurses
Simulation Scenarios 42
Expected Outcomes
Short-term: Implement effective communication and efficient teamwork concepts, such
as the following TeamSTEPPS tools: brief, situation awareness, cross-monitoring, CUS,
and the two-challenge rule.
Long-term: Demonstrate improved patient outcomes for any type of obstetrical
complication.
Facilitator Notes
Below are tips to help the facilitator conduct the
simulation.
A task trainer birthing simulator (used with a
standardized patient actor) or high-fidelity
birthing simulator is recommended to conduct
this scenario so that participants can
appropriately perform release maneuvers for SD.
Throughout this scenario, participants will be tasked with identifying opportunities to apply
effective communication and efficient teamwork skills such as the ones recommended by
TeamSTEPPS. The tools and strategies specific to
this scenario include: brief, situation awareness,
cross-monitoring, CUS, and the two-challenge
rule. Visit AHRQ’s website for more information
about TeamSTEPPS.
After handing off the patient to the participants
(i.e., the L&D team members), they should
discuss the patient’s current status and potential
complications that might occur (brief). The discussion should include any steps the participants
will perform if complications arise. This step in the scenario is meant to validate the importance
of proactive discussion so that the team can promptly recognize complications and swiftly
execute interventions.
The facilitator will need to provide the physician order for oxytocin reflecting a larger-than-
standard dose. The participant (nurse) should speak up to alert other team members of the
potential for patient harm (CUS or two-challenge rule).
During the SD event, participants should be aware of what to look for (situation awareness)
and ready to assist each other in performing their tasks as needed (cross-monitoring). Once
a complication is recognized and shared with the team and treatment efforts are initiated,
attention to the patient’s treatment response is paramount (situation awareness).
NOTE
The facilitator has the option to expand
this scenario into a neonatal resuscitation
exercise based on meconium aspiration.
NOTE
If you prefer not to use the TeamSTEPPS
tools, a description of what is expected
from the participants is provided. Simply
disregard the words in parentheses in the
paragraphs below.
Simulation Scenarios 43
Communication with the L&D team regarding the time elapsed in resolving the SD should be
included as part of the process.
It is recommended that participants perform this
scenario twice in the same training session so
that learning and re-enforcement of
communication and teamwork skills can be
applied to their clinical practice.
Throughout the scenario, the facilitator will need
to provide data for the following: elapsed time,
dilation status, FHR data, and SD presentation
(see “Scenario Steps” on page 45). The FHR
data should be displayed on a strip or paper
model near the monitor. If an actual monitor is
being used, program the FHR data according to
the “Scenario Steps.”
Additionally, to facilitate the time needed for the
scenario session, the facilitator has the option to
compress (speed up) time as needed. Make the
participants aware of the time by either
displaying the time in a visible location or stating
the time throughout the scenario.
Manual setup for the L&D process requires moulage (simulated body fluids), including mild
vaginal bleeding and meconium. See “Scenario Setup” for more details. Moulage recipes and
instructions can be found on the Internet.
Equipment and Supplies
Hospital bed (birthing bed preferred) and bed sheet
Mattress pad/chuck pad/blue pad
Plastic tarp/covering, if using moulage
Step stool for nurse
Stool for provider
Clear plastic bag for baby (amniotic sack this is helpful if adding meconium as part of
the scenario)
Umbilical cord/plastic tubing (secured to baby)
Umbilical cord clamp
DEFINITIONS
CUS is a tool to use when a conflict of
information is identified that warrants a
team member voicing his/her Concern,
that he/she is Uncomfortable, and a
Safety issue exists. Each facility or
practice may develop a unique word,
phrase, or signal to alert the other
team members without alarming the
patient/family.
The two-challenge rule is a tool to
use when a conflict of information is
identified that warrants a team
member speaking up, alerting, and/or
questioning other team members at
least twice before proceeding any
further with a task or intervention.
Simulation Scenarios 44
Baby blanket
Scrub gowns and shoe covers, if using moulage
Telephone
Call light
Scenario Setup
Patient
Mother (actor with task trainer or high-fidelity birthing simulator):
o Hospital gown and slipper socks (for the actor)
o IV cannula
o Task trainer (female torso)/birthing simulator
o Fetal heart monitor with strips/printouts demonstrating fetal reassurance and fetal
distress
o Moulage, if desired
Baby (doll or task trainer/simulator):
o Clear plastic trash bag, 4-gallon (recommended to simulate the amniotic sac and
minimize cleanup if moulage is used)
Partner (actor to assist the patient in labor and delivery):
o If using task trainer torso, partner can assist with holding torso in place
Room
Place bed sheets and mattress pad on bed.
If using moulage, place tarp at the birthing end of the bed to protect bedding and the
floor.
Position mother (actor with task trainer or high-fidelity simulator) on bed.
Place step stool and provider stool in room for easy access.
To prep baby, place doll or manikin in a clear plastic bag with head at the closed end and
feet at the opened end.
Poke a hole in the closed end of the bag (ruptured membranes) so that the baby’s head
is free of the bag.
Place any amount of meconium moulage inside the bag coating the body of the baby (if
desired).
Simulation Scenarios 45
Place the baby and bag inside the task trainer with head engaged through the vaginal
opening exhibiting the “turtle sign.”
Mother and her birthing partner (actors) will need to hold the task trainer and the baby’s
feet in place throughout the delivery process.
Successful newborn delivery may result at the facilitator’s discretion.
If using a high-fidelity birthing simulator, set up the birthing module for SD as instructed
through the simulator’s owner/operator manual.
Scenario Commencement
Handoff Report to Participants
A laboring patient (G2P1) was admitted at 39 weeks gestation to L&D by an on-call obstetrician
from an OB clinic. The patient’s previous medical history includes a pregnancy in her teens and
anemia. Ultrasounds during prenatal care at the clinic were normal. Records indicate a 49-
pound weight gain throughout the pregnancy.
Upon assessment, the patient is approximately 4 cm dilated with membranes ruptured and mild
vaginal bleeding noted. Baseline FHR is in the 140s without decelerations. The fetal weight is
estimated at 8.5 pounds.
Scenario Steps
Patient Response and Participant Actions
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
0800 Dilation: 4 cm
Mild vaginal
bleeding
Membranes
ruptured
FHR: 140‒150
Moderate variability
No decelerations
Discuss the patient’s
status and potential
complications with staff
Patient status and potential
complications discussed with
staff (brief)?
Yes No
Simulation Scenarios 46
TIME
PATIENT
CONDITION/
RESPONSE
PARTICIPANT ACTIONS TASKS COMPLETED
0800 Same as above Augmentation with
oxytocin; wrong dosing
order provided (see
“Facilitator Notes”)
Nurse asks about the
oxytocin order at least
twice or states safety
concerns
Oxytocin order questioned
(CUS or two-challenge
rule)?
Yes No
1200 Fully dilated
SD
OB physician
communicates SD with
L&D team, patient, and
partner
SD maneuvers applied
Information about SD
communicated to the L&D
team?
Yes No
Effective communication with
patient and partner?
Yes No
1203 SD L&D team is informed of
elapsed time in resolving
the SD event
Elapsed time is
communicated to the team
(situation awareness/
cross-monitoring)?
Yes
No
1204 Delivery of healthy
baby
N/A N/A
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
What did you think was happening?
What did you do and why?
Do you think your interventions were helpful? Describe how. If not, explain why.
Simulation Scenarios 47
Did the team members communicate effectively with each other? Provide examples.
Did the team members communicate effectively with the patient and the partner?
Provide examples.
How efficient was the teamwork with team members and with the patient? Provide
examples.
What aspects of this scenario exercise can you apply to your clinical practice? How might
you apply those aspects?
Resources
Agency for Healthcare Research and Quality: TeamSTEPPS
D E N T A L
P R A C T I C E
Simulation Scenarios 49
DENTAL PRACTICE: AGGRESSIVE PATIENT SCENARIO
The purpose of this scenario is for participants to use appropriate communication skills and
initiate protective measures to address disruptive behavior in the dental practice setting.
De-escalation techniques should be performed to maintain safety for the staff and other
patients. For more details, refer to the “Facilitator Notes” on page 50.
This scenario is written for a dental practice setting; however, it can be reconfigured for any
healthcare environment.
Scenario Background
Information for the Facilitator
A receptionist is sitting at the front desk of a
dental practice when a male patient walks in and
heads straight to the front desk. He appears
agitated and irritable. The receptionist recognizes
the patient from his recent appointment, during
which he had a root canal. Sensing that
something is bothering the patient, the
receptionist asks if she may assist him. The
patient states that his root canal was not done
properly, and he wants a copy of his patient
records and a monetary refund.
The receptionist attempts to ask questions about the root canal, but the patient becomes
aggravated and says, “I want my records and my money NOW!” The receptionist replies that
she will get the practice manager, at which point the patient slams his fist on the front desk and
yells at the receptionist to quit wasting his time and get him what he wants.
Learning Objectives
During this scenario, participants will:
Recognize a potentially volatile situation (risks of escalation)
Provide appropriate and timely interventions (de-escalation techniques)
Demonstrate effective communication with the patient and team members
Activate emergency response to protect staff and other patients from harm
Target Participants
Dental practice staff
Simulation Scenarios 50
Expected Outcomes
Short-term: Apply appropriate de-escalation techniques to avoid patient and staff harm
and to safely resolve the crisis. Activate the emergency response system (law
enforcement) to subdue and remove the threat.
Long-term: Recognize early signs of an escalating crisis and the need to promptly notify
staff. Understand when de-escalation strategies are not calming the patient. Know when
to promptly activate the emergency response system to ensure patient and staff safety.
Facilitator Notes
Below are tips to help the facilitator conduct the simulation.
Because communication and de-escalation techniques are the main objectives of the scenario, a
standardized patient (SP) actor can best fill the role of the patient. Provide scripting and general
behavior guidelines to the SP prior to the simulation session so that he can deliver appropriate
responses to the participants.
Additionally, the facilitator should determine the time length of the patientreceptionist
encounter. For example, if the facilitator wants to assess whether the receptionist will have the
patient step into another room (away from other patients) to discuss his concerns, having the
patient remain composed for a longer period will be necessary. This option will enable the
facilitator to assess staff members’ de-escalation skills in various situations.
If de-escalation training is not available within your dental practice, contact local emergency
medical services or law enforcement to inquire about possible staff training opportunities. In
addition, the link located in the “Resources” section on page 52 provides information about
de-escalation techniques.
Times listed under “Scenario Steps” serve as a guide only. Depending on the participant, the
facilitator might want to shorten or lengthen the time.
Equipment and Supplies
Front desk
Chairs (waiting room)
Telephone
Scenario Setup
Patient
Street clothes
Simulation Scenarios 51
Room
Align chairs to resemble a waiting room
Position front desk opposite from entry door
Scenario Commencement
Handoff Report for Participants
You are the receptionist for a dental practice. You are seated at the front desk to assist patients
as they enter the office.
Scenario Steps
Patient Response and Participant Actions
TIME
PATIENT
CONDITION/RESPONSE
PARTICIPANT
ACTIONS
TASKS COMPLETED
1300 Behavior: Irritable and
demanding
Use appropriate
communication
techniques
Appropriate communication
used?
Yes No
1301 Behavior: Increasing
irritability
Apply appropriate
de-escalation
techniques
Appropriate de-escalation
techniques applied?
Yes No
1302 Behavior: Slams fist on the
front desk
Continue with
de-escalation
techniques and notify
coworkers
Continued to apply
de-escalation techniques?
Yes No
Coworkers notified?
Yes No
1303
Behavior: Threatening
harm to staff
Notify emergency
response system (law
enforcement)
Emergency response
system notified?
Yes No
Simulation Scenarios 52
Debrief
Responses to the debrief questions are meant to reflect learning; they require more than yes or
no answers.
What did you think was happening?
What did you do and why?
Do you think your interventions were helpful? Describe how. If not, explain why.
Did the team members communicate effectively with each other? Provide examples.
Did the team members communicate effectively with the patient? Provide examples.
How was safety addressed and maintained throughout the scenario (e.g., applied de-
escalation techniques, notified other staff members, and notified emergency response
system)?
What aspects of this scenario exercise can you apply to your workplace protocols? How
might you apply those aspects?
Resources
Western Journal of Emergency Medicine:
Verbal De-escalation of the Agitated Patient:
Consensus Statement of the American Association for Emergency Psychiatry Project BETA
De-escalation Workgroup
5814 Reed Road
Fort Wayne, IN 46835
www.medpro.com | 800-463-3776
© 2017 MedPro Group Inc. All Rights Reserved.
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