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Post date: 05/09/2013 | Time to read article: 7 mins

The information within this article was correct at the time of publishing. Last updated 18/05/2020

robodocDr Adam Hexter explores the role of surgical simulation in enhancing patient safety

Patient safety in healthcare has never been more in the spotlight. Events such as the Stafford Hospital scandal and the subsequent Francis Report have raised awareness that at times patients receive suboptimal care. There is a real drive to place patient safety at the core of service delivery.

The appreciation of patient safety is not just a recent phenomenon. Indeed, the Hippocratic Oath includes the promise to abstain from doing harm and a guiding principle for doctors is primum non nocere, first – do no harm. Nevertheless, medical error remains an important cause of patient morbidity and mortality, with approximately one in ten patients in NHS hospitals experiencing an adverse event.

This has financial implications for the NHS, with the total cost of adverse events in terms of additional bed days estimated to be £1 billion per year. In particular, surgical specialties account for a significant proportion of adverse events.

Safety in surgery

Training time has been significantly reduced and therefore surgeons must achieve steeper learning curves in less time

Surgery is renowned for being a highrisk profession and faces considerable challenges in the 21st century. Modern procedures require new skill sets due to advances in technology and understanding – this is epitomised by minimally invasive surgery (MIS). Despite advantages, such as reduced hospital stay, better cosmesis and less pain, MIS is more technically challenging for the surgeon. However, as a result of the European Working Time Directive, training time has been significantly reduced and therefore surgeons must achieve steeper learning curves in less time.
Traditionally, surgical training has been by an apprenticeship model, whereby trainees “see one, do one, and teach one”. However, problems with this approach are numerous and include random case exposure and subjective feedback. Such flaws were exposed when laparoscopic surgery was introduced for cholecystectomy instead of open procedures, when inadequate laparoscopic training resulted in unacceptable levels of surgical complications, such as bile duct injury.

The rationale behind simulation

The promise of surgical simulation is that it can prevent such mistakes happening again. With the emergence of the technically demanding Single Incision Laparoscopic Surgery (SILS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES), it is essential that patients are not exposed to preventable harm. Hence the surgical field has explored various solutions, with simulation at the forefront.

Simulation is defined as “a technique to replace or amplify real-patient experiences with guided experiences, artificially contrived that evokes or replicates substantial aspects of the real world in a fully interactive manner”.2 There are many different types of simulators and these are not just limited to surgery. Systems used include simulated patients, interactive manikins, task (box) trainers and, the most sophisticated, virtual reality (VR) simulators.

Technical and non-technical performance

There is increasing evidence showing that simulation-based training improves technical skills. Gurusamy et al published a Cochrane review involving 23 studies and 622 participants, which investigated the effect of VR simulation on laparoscopic skill attainment. The conclusion was that VR training is well tolerated and leads to reduced operating times and fewer errors than standard training.3

Recent advances in imaging technology have furthered the scope of simulation to improve technical performance. An example is patient-specific simulation, which involves imaging and uploading a patient’s anatomy onto a VR simulator. This enables a surgeon to practise the most difficult parts of an operation on their patient’s exact anatomy beforehand. VR simulators are also useful as a means of “warming up” because surgeons who warm up for laparoscopic cholecystectomy demonstrate better performance in the operating theatre.4

VR training is well tolerated and leads to reduced operating times and fewer errors than standard training

Surgery has progressed beyond a sole focus on practical skills, and there is increasing appreciation of non-technical skills, such as communication, teamwork and decision-making. These “softer skills” can also be developed through simulation, such as team-based simulated operating suites (SOS). For instance, implementation of the WHO Surgical Safety Checklist by the multidisciplinary team has been done by using SOSs.

Development of simulation-based curricula

The realisation that simulation can lead to the acquisition of proficiency in a safe and structured environment has led to the development of simulation-based curricula. The fundamental principle is that a trainee can only progress along the defined curriculum when they demonstrate proficiency in a task.

Having reached proficiency on a simulator, trainees still face the challenge of translating their skills to the complex clinical environment of the operating theatre – thus subsequent supported clinical exposure is necessary. Hence simulation should be perceived as a step between classroom instruction and actual clinical practice on real patients.

The fundamental principle is that a trainee can only progress along the defined curriculum when they demonstrate proficiency in a task

An example of a successful curriculum is the Fundamentals of Laparoscopic Surgery (FLS) programme in the USA. Passing FLS is a requirement for all surgical residents in order to complete their residency. Although still in its infancy in the UK, the inevitable evolution towards simulation-based training is reflected by the words of former Health Minister Lord Ara Darzi: “We are working with NHS colleagues to develop a new strategy for simulation-based training in order to ensure the best training for doctors and the best quality of care for our patients.”

What challenges does simulation face?

Despite the recognised benefits, simulation faces some significant challenges and obstacles to widespread use in the clinical setting, most notably its high costs. Despite the expansion of simulation devices, there are few examples of integration of simulation into medical curricula.

However, as evidence accumulates, societal pressure for healthcare to embrace simulation will increase. Studies have now demonstrated both improvements in service delivery and financial benefits following simulation training. For example, a simulation-based education programme for central venous catheter insertion led to reduced catheter-related bloodstream infections. Although the annual cost of the programme was $112,000, savings of $700,000 were gained following incidence of infection.5

Learning from other industries

Aviation is often likened to surgery, as it is a high-risk organisation where safety failings have potential for immense public harm. In response to aircraft disasters, aviation has utilised simulation to achieve robust selection and training methods. With subsequent improvements in the safety of aviation, there have been many calls for healthcare to emulate aviation and utilise simulation.

The validity, reproducibility and ability to standardise assessment means that simulation has numerous potential uses, such as selection

The validity, reproducibility and ability to standardise assessment means that simulation has numerous potential uses, such as selection. In fact, simulated technical skill tasks are already used when selecting candidates for the UK cardiothoracic surgery programme. Furthermore, simulation has been proposed as a tool for the GMC’s revalidation of doctors. Hence simulation is likely to feature heavily throughout the careers of today’s junior doctors.

Can simulation enhance patient safety in surgery?

Improving patient safety remains a significant challenge for the NHS, with surgery in particular facing considerable challenges. Undoubtedly, simulation is a powerful learning tool that allows safe, structured and efficient training without exposing patients to preventable harm. Moreover it has the potential to reduce the cost of clinical care, minimise adverse events and enhance patient outcomes.

Consequently many believe the acquisition of surgical psychomotor skills is best achieved in the context of a simulated environment rather than on real patients. Put simply by Sir Liam Donaldson, England’s former chief medical officer: “Simulators reduce errors and make surgery much safer.”

Useful info

  • DH, An Organisation with a Memory (2000)
  • DH, Safety First (2006)
  • High Quality Care for All (2008)


  1. Vincent C, etal, Adverse events in British Hospitals: Preliminary Retrospective Record Review, British Medical Journal (2001)
  2. Society for Simulation in Healthcare, What is Simulation? (2009, May 1)
  3. Gurusamy K, etal, Systematic Review of Randomized Controlled Trials on the Effectiveness of Virtual Reality Training for Laparoscopic Surgery, British Journal of Surgery (2008)
  4. Calatayud D, etal, in a Virtual Reality Environment Improves Performance in the Operating Room, Annals of Surgery (2010)
  5. Cohen ER, et al, Cost Savings from Reduced Catheter-related Bloodstream Infection After Simulation-based Education for Residents in a Medical Intensive Care Unit, Society for Simulation in Healthcare (2010)

Case study – Simulation in Scotland

The feeling of losing control of a surgical situation is difficult to describe and variable to the individual. Discussion of how to manage these situations becomes much more realistic and valid when that personal feeling is recreated. The simulations on the Managing Surgical Crisis course in Dundee provide experience of difficult scenarios, such as bleeding, bile-duct damage, and trocar injuries in real time. These scenarios are a rigorous test of leadership and logical processing of a stressful situation.

The course focuses on how to take charge of the situation, lead the team and ultimately achieve the safest possible outcome for the patient

The course teaches a structured approach to dealing with a crisis. Participants commence the scenario as the lead surgeon in a common surgical procedure. As the scenario plays out an unexpected complication occurs. The course focuses on how to take charge of the situation, lead the team and ultimately achieve the safest possible outcome for the patient.

The participant is encouraged to use the members of the team and resources available. The course algorithm guides the surgeon to establish the problem and inform the team of the situation and ensure that there is a shared understanding of the scenario. Distractions such as people talking in the background or team members not grasping the gravity of the situation add to the authentic feel. Techniques such as establishing a sterile cockpit and graded assertiveness are taught and are useful in establishing understanding the situation.

Once the surgeon has gained hands-on control, the decision-making process is key. This involves a range of skills including communication, delegation and team management. An awareness of one’s own limitations is necessary in order to proceed safely.

An awareness of one’s own limitations is necessary in order to proceed safely

At the end of the scenario a thorough debrief with experienced faculty members to help to reconcile the thought processes involved and the various strategies that could be employed to safely resolve the situation. In the past, a tutorial or lecture may have been the way in which the management of these surgical crises were taught. Having experienced the beads of sweat and feeling of being under the spotlight I am sure that simulation is a far superior manner in which to learn about surgical crisis management.

Having taken this course, I now feel more confident that when faced with a difficult surgical scenario I will be better equipped to deal with the initial cloudiness and form a structured approach to safely control the situation. I will certainly be recommending this course to my colleagues as a way of developing their non-technical skills and improving patient safety.

Mr Colin McIlmunn attended the Managing Surgical Crisis Course, a joint venture between the Scottish Clinical Simulation Centre and the Cuschieri Skills Centre. Visit:

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