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Coping with Simulation Case Derailment

Posted Apr 26 2013 12:00am

Author: Corey Heitz, MD
Peer Reviewer and Editor: Nikita Joshi, MD

“The best laid plans of mice and men...”

The simulation scenario starts and things are going well. The learners are on their game. Instability - recognized, managed. Initial orders - done. And then it all falls apart. We’ve all been there.
  • The learners zigged when they should have zagged (Sepsis?? The pt’s having an AMI!)
  • They missed the KEY item that would have given the diagnosis, now they’re stuck in nowhere Land.
  • They’re about to perform a painful procedure on someone who doesn’t need it!!

The sim case has officially derailed.

Whatever the situation, you as the facilitator need to prepare how to fix sim-case-derailment in advance. If you are like many of us, and believe in realism, then you need to know what you’re going to do to keep the scenario going, or, when you need to break realism and “fix it.”

The following are potential issues and options for how to work through or around issues that arise during simulations. Options can be separated into “adapting” the case (keeping your changes within the scenario) and “restoring” the case (fixing it, often from without).

The underlying concept to any scenario rescue or modification is to remember: 
What are your objectives?

Learner Error (misdiagnosis, missed exam finding, wrong med/dose)
    let it play out     confederate redirection     patient redirection/cues     few good options if trying to maintain realism – if egregious enough, pause, debrief, resume/restart
Technology Failure
    let it play out - new case on the fly?     confederate correction - “breath sounds are decreased on the right, doc”     confederate redirection - “let me get a manual blood pressure on him, I don’t trust that reading”     restart case - “sorry, let’s run it back”     pause case, fix problem, resume     “voice of God” - tell them what they’re supposed to be seeing
Dangerous actions (uncapped needle, scalpel, etc)
    confederate correction     patient cueing     address during debrief     pause case, resume once corrected
Mismatched competency (case too easy or too hard for the learners)
    have senior physician step in “Hey I heard you were having trouble...”     modify case on they fly (make him better/worse)     end case, restart with a more straightforward one



When applying any of the above corrections, or others not listed here, remember to consider your original objectives. Would letting the scenario progress naturally, albeit differently than planned keep the learner from meeting their objectives? Interrupting the case for correction or redirection may ruin the flow and result in artificiality.

Other considerations for any correction:
  • Correcting within the case must follow scenario logic -- i.e. patients don’t magically improve!
  • “In-scenario” fixes are psychological and not physical. Any form of communication may be used. Consider confederate consultant questions such as, “Are you SURE it’s atrial fibrillation?”
  • Another “in scenario” fix to restore (not adapt) the case could be as simple as having the nurse confederate correct the vital signs (“sorry, we haven't updated the monitor to the new patient”)
  • For “out of scenario” fixes, think about at what point you should restart the case or simply resume the case.

Videos Highlighting Correction Techniques
Below are two videos showing options for case management when unexpected events occur.


Wrong Type of Shock



Wrong Patient

Acknowledgements: adapted from “Keeping it Real When Faking it” presented at CORD AA 2010, Mike Smith MD, Thomas Noeller MD Corey Heitz, and Raymond Ten Eyck MD.

Further reading:
Dieckmann P, Lippert A, Glavin R, Rall M. When Things Do Not Go as Expected: Scenario Life Savers. Simul Healthc. 2010;5:219.

Images 1 , 2
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