Pediatric Annals

Special Issue Article 

Simulation in Pediatrics: A Learning Lab for Education, Quality Improvement, and Patient Safety

Priti Jani, MD, MPH; Bridget M. Wild, MD


Simulation-based medical education is an experiential modality that has evolved over the last 60 years, amassing evidence as an efficacious tool for skill acquisition and care improvement. We review the underlying theory, core defining principles, and applications of medical simulation broadly and in pediatrics in hopes that it can be accessible to every pediatric clinician regardless of practice environment and resources. Any situation where there is risk of harm to a patient or clinician can be simulated for practice, reflection, and re-practice. Whether preparing for clinic-based emergencies, new hospital units, or new daily workflows, simulation is valuable to novice and master clinicians for individual and team care enhancement. [Pediatr Ann. 2021;50(1):e13–e18.]


Simulation-based medical education is an experiential modality that has evolved over the last 60 years, amassing evidence as an efficacious tool for skill acquisition and care improvement. We review the underlying theory, core defining principles, and applications of medical simulation broadly and in pediatrics in hopes that it can be accessible to every pediatric clinician regardless of practice environment and resources. Any situation where there is risk of harm to a patient or clinician can be simulated for practice, reflection, and re-practice. Whether preparing for clinic-based emergencies, new hospital units, or new daily workflows, simulation is valuable to novice and master clinicians for individual and team care enhancement. [Pediatr Ann. 2021;50(1):e13–e18.]

The adage, “see one, do one, teach one,” is referenced by medical practitioners when speaking to their trainees regarding the conventional methodology for knowledge and skill acquisition prior to autonomous performance. Although emphasizing a key principle in developing professional expertise, observation, it oversimplifies the curricular elements necessary for medical professionals to achieve proficiency. Despite the standardized curriculum for health care trainees and consistent ability to provide a solid knowledge base, medical systems vary considerably in the characteristics of their instructors, mentorship, curricular development, and patient populations. To develop professional expertise, a practitioner must prepare in their domain, experience the appropriate combination of variation, and have the opportunity to apply their knowledge. In doing so, the learner develops schemata specific to their domain of practice along with a set of expectations. These are ultimately used to achieve a higher level of proficiency in cognitive, psychomotor, and affective skills.

In medicine, similar to aviation and military training, the opportunities for gaining experience on the job are limited by the rarity of high-stakes events and vulnerability of acquired knowledge and skills to decay. Furthermore, as our diagnostic and predictive capabilities have advanced, the volume and frequency of some procedures has dramatically decreased, making real world mastery difficult to achieve. For example, with the advancements in noninvasive ventilation and surfactant administration, fewer neonates require intubation in the delivery room1 and with each successive guideline review, fewer infants must undergo lumbar puncture in the setting of fever.2 Regardless, when high stakes, low volume interventions are needed, we must be prepared to perform them well.

Medical education continues to rely on the apprenticeship model as the primary form of training. Unfortunately, significant gaps in the ability of this model to provide appropriate preparation for independent practice have been demonstrated. Assessments reveal pediatric house staff at the end of their training have deficiencies in both procedural competencies as well as resuscitation care.3–5 The challenges in knowledge acquisition and retention have sparked numerous simulation-based investigations to identify the ideal methodology toward strengthening the current model. Evolving over the past 60 years, simulation has emerged as a “a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.”6 This technique, simulation-based medical education (SBME), provides consistent opportunities for practice with limitless variation and has a rising body of evidence to support its success in improving knowledge acquisition, retention, and ultimately clinical practice and patient safety.7 The simulation lab also provides ongoing opportunity to investigate and refine curricula, quality improvement interventions, and system safety processes. Most importantly, it affords an environment to develop professional expertise without risk to patients. Given these benefits, its use is increasing in the medical field and is commonly used in pediatrics.8

Here, we describe the use of simulation in supporting medical education, inclusive of its educational application to quality improvement and patient safety. This article serves as a blueprint, highlighting the most effective aspects of medical simulation. Specifically, we focus on the following categories: technical and procedural skills; professionalism, communication, and leadership; and quality improvement and patient safety.

Although some may consider medical simulation a resource intensive modality, it can occur anywhere under the right guidance and has variable forms. To be considered medical simulation, there must be a genuine attempt to create an immersive experiential educational environment for the learner(s) (Table 1).9 A myriad of other best practices are well studied and endorsed by the academic simulation community. They include (1) pre-briefing to create a safe environment; (2) prescribing specific modalities to ideal learning objectives such as high-fidelity manikins for cardiac arrest resuscitation practice; (3) incorporating evidence-based practice standards; and (4) methods of debriefing paired with learner experience and learning objective types.10

Components of Medical Simulation

Table 1.

Components of Medical Simulation

Grounded in these components, simulation takes on many different forms differentiated by the location, equipment, and personnel involved (Table 2). The simulator may be a human patient simulator (manikin), a simulated live patient (standardized patient), a simulated body part (task trainer), or any of the latter three taking place in the virtual environment.11

Forms of Simulation

Table 2.

Forms of Simulation

Theory and Evidence

Simulation-based education emulates multiple validated adult learning theories, the most notable being Kolb's experiential learning theory. Kolb describes learning as occurring during a cycle with the following four elements: concrete experience, reflective observation, abstract conceptualization, and active experimentation (through concrete experience).12 In the simulated medical scenario, the learner gains concrete experience as they “do” and “feel.” Postsimulation, as they debrief, they move through the cycle elements of reflective observation and abstract conceptualization. Under the guidance of a trained facilitator, the learners reflect on the scenario as well as the actions and decisions taken. Often the self-reflection can be paired with objective data, such as video playback or intervention quality and timeliness in comparison with evidence-based standards of care, allowing for discussion of potential future strategies for improved medical management. In this way, the learner is armed with abstract concepts to apply during the active experimentation phase in future simulations or real-life scenarios. This cycle creates a more complex and long-lasting memory that can inform future behavior and meta-cognitive steps.

The exponential increase in evidence favoring SBME supports the argument that Kolb's experiential learning theory has proven true. Reviews of simulation-based studies demonstrate learners have improved confidence, knowledge, skills, communication, and teamwork.13 In a meta-analysis comparison of SBME with traditional clinical education, SBME demonstrated superiority in the acquisition of a medical skills. These included proficiencies such as advanced cardiac life support, thoracentesis, and cardiac auscultation.14

In addition, simulation serves as the testing ground for various methodologies and curricular elements. Explorations are ongoing to determine the ideal usages for different forms of simulation, such as traditional simulation with postsimulation debriefing versus interruptions to allow for in-time action reviews and deliberate practice, deliberate practice versus mastery learning, and standardized patients versus manikin-based as well as location (in situ versus simulation lab versus virtual).

Two key strategies have emerged as contributing to the success of simulation: deliberate practice and simulation-based mastery learning. Coined by K. Anders Ericsson, deliberate practice plays a fundamental role in the development of expertise. “Deliberate practice involves repetitive performance of intended cognitive or psychomotor skills in a focused domain, coupled with rigorous skills assessment.”9 Simulation allows the learner to enter Kolb's learning cycle repetitively, fostering opportunity for deliberate practice. This practice can be extended to achieve mastery learning, where all learners attain an objectively measured uniform level of mastery with variation in the time needed to achieve the mastery.9 Importantly, simulation-based mastery learning has exhibited retention and translation of skills acquisition, inclusive of psychomotor, communication, and cognitive, to improved patient outcomes and quality of care.15

Technical and Procedural Skills

As the evidence amasses favoring SBME, the uptake by medical educators has been similarly exponential. A recent survey highlighting this use found 92% of medical schools, 86% of teaching hospitals, and 89% of pediatric clerkship directors have simulation integrated in their curricula.13 In particular, training programs are leaning more on simulation for the development of proficiency in technical and procedural skills. The American College of Graduate Medical Education (ACGME) accepts simulation-based performance as a substitute to the demonstration of skills performed in the clinical environment.16 Additionally, simulation task trainers are used to support trainees in achieving the ACGME directed procedural competence in skills such as lumbar puncture and peripheral intravenous access.17,18 The demand for these task trainers to support education has increased as work hours decrease and specialized teams or personnel take on procedures (eg, vascular access teams), further limiting opportunities to develop expertise in the clinical environment. The modality of created opportunities is bolstered by research demonstrating translation of simulation-acquired skills into the clinical space and reduction in errors.18,19

Professionalism, Communication, and Leadership

Teaching affective skills such as professionalism, communication, and leadership have long presented a challenge in medical education. The Joint Commission ( reported that greater than 60% of sentinel events across 3,000 hospitals between 1995 and 2004 were attributed to poor communication, thereby supporting the importance of these skills and further development of simulation as a modality to improve provider communication.20 Initially used exclusively to assess affective skills (ie, during objectively structured clinical exams), simulation is now resourced to develop and improve upon these important proficiencies. Examples include delivering bad news, resolving conflicts, and disclosing medical errors. During simulation, communication skills can be taught using standardized patients or via role play. Standardized patients are people trained to act as patients during the assessment and education of trainees. Role play allows for the simulation of a communication between two learners where one learner plays the role of the patient. Role play was successfully used during the I-PASS ( study to improve handoff practices and team communication.21 Although the development of standardized patient programs is time and money intensive, the fidelity is premium. However, role playing allows for building of empathy skills and can be done relatively inexpensively. Similarly, simulation-based curricula allow for the procurement of leadership and crisis resource management skills.22,23

Quality Improvement and Patient Safety

With an established foundation as an effective resource for skills acquisition and assessment, simulation has pressed onward as a tool for seasoned clinicians and health systems for clinical performance evaluation and targeted preparation. The quality of resuscitation team performance, timing of resuscitation tasks, and cardiac arrest survival rates are superior when teams participate in simulation-based trainings.24,25

Sometimes, the objective of simulation is to test the system in which we deliver care for the benefit of improved patient safety. In-situ simulation (occurring in the actual patient care environment with the same team composition as in actual practice) can function as a probe revealing latent safety threats at the individual, team, system, and organizational level. For example, the simple purchase of new hospital beds could result in an inability to deliver effective chest compressions or even a need to change position of mounted equipment to eliminate risk of falls or injury. Furthermore, clinicians can determine the ideal model of care, turning “work as imagined” (what we believe should happen) into “work as done” (the work that actually happens). “Day in the Life” simulation serves to test new clinical spaces and can identify latent safety threats such as lack of critical equipment, issues with emergency alarms, and non-functioning equipment.21 Similarly, management of medical conditions may be appraised. This is evident in the “Prevalence of Errors in Anaphylaxis in Kids” study where investigators used in-situ simulation to identify latent safety threats across multiple institutions in the management of anaphylaxis. This study identified patterns of deviation from “work as imagined” during the management of anaphylaxis and identified practice characteristics toward determining the ideal model of care, noting that nurse experience with anaphylaxis treatment was linked with decreased errors related to epinephrine administration.26 Although recreating sentinel events to study root causes can be incredibly helpful, this is a special type of simulation that should not be undertaken without very careful attention to psychological safety of involved team members, and in the hands of an experienced facilitator. In sum, whether it be pre-identification of safety events, team preparation to achieve “work as imagined,” stressing systems or teaching to fill knowledge gaps fueling poor quality, simulation plays a significant role in strengthening the quality and safety of medical systems.

Special Circumstances: COVID-19

Simulation has long been an experiential tool in medical school for learning mass casualty management and large-volume, low-resource triage. Simulation allows for the rapid dissemination of information and promotes changes in behavior. It naturally integrates into the hospital safety and quality infrastructure and can be leveraged to quickly organize and iteratively test a hospital's processes, equipment, and personnel during new situations. Formerly described as a “backburner” training tool, simulation is now considered a first-choice tool in preparing people, teams, and systems for the COVID-19 (coronavirus disease 2019) pandemic.27 Whether as just-in-time training at the beginning of a shift or in universal employee check offs (eg, personal protective equipment donning and doffing), simulation was relied upon to prepare frontline providers in new clinical protocols.27 Additionally, as new clinical spaces were developed rapidly, in-situ simulation drills were conducted to evaluate the spaces, train providers, and implement new practices.28 Iterative testing was used to develop and implement protocols, develop mitigation plans, and determine the best model of care for all patients in the setting of the pandemic.


A true simulation educator approaches learners with the basic assumption that everyone participating is intelligent, capable, cares about doing their best, and wants to improve.29 Naturally, simulation is the science of investigating how people, teams, and systems can achieve “their best” and “improve” as well as translating the identified optimal model of care to clinical practice. Investigations in the simulation lab work to identify, formulate, evaluate, and educate on the ideal methods for achieving best practices in medical education, patient safety, and quality of care. In doing so, simulation also serves as a tool to empower health care professionals to achieve their best by addressing opportunities for growth, relating relevance to their daily work, highlighting strengths, and providing a pathway for continued improvement. From novice learners to crisis team training and system testing, simulation spans a wide scope of application in its service to health care systems. It has never been more relevant than now as a cornerstone technology in helping hospitals to prepare and optimize their model of care during this unprecedented global health crisis.27 Moving away from “see one, do one, teach one,” the evidence supports a new maxim, “see one, sim one, do one, repeat.”


  1. Robinson M-E, Diaz I, Barrowman NJ, Huneault-Purney N, Lemyre B, Rouvinez-Bouali N. Trainees success rates with intubation to suction meconium at birth. Arch Dis Child Fetal Neonatal Ed. 2018;103(5):F413–F416. doi:10.1136/archdischild-2017-313916 [CrossRef] PMID:29636384
  2. Mercurio L, Hill R, Duffy S, Zonfrillo MR. Clinical practice guideline reduces evaluation and treatment for febrile infants 0 to 56 days of age. Clin Pediatr (Phila). 2020;59(9–10):893–901. doi:10.1177/0009922820920933 [CrossRef] PMID:32468838
  3. Gaies MG, Landrigan CP, Hafler JP, Sandora TJ. Assessing procedural skills training in pediatric residency programs. Pediatrics. 2007;120(4):715–722. doi:10.1542/peds.2007-0325 [CrossRef] PMID:17908757
  4. Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DR. Assessing pediatric senior residents' training in resuscitation: fund of knowledge, technical skills, and perception of confidence. Pediatr Emerg Care. 2000;16(2):73–76. doi:10.1097/00006565-200004000-00001 [CrossRef] PMID:10784204
  5. Buss PW, McCabe M, Evans RJ, Davies A, Jenkins H. A survey of basic resuscitation knowledge among resident paediatricians. Arch Dis Child. 1993;68(1):75–78. doi:10.1136/adc.68.1.75 [CrossRef] PMID:8435013
  6. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13(suppl 1):i2–i10. doi:10.1136/qshc.2004.009878 [CrossRef]
  7. Aggarwal R, Mytton OT, Derbrew M, et al. Training and simulation for patient safety. Qual Saf Health Care. 2010;19(suppl 2):i34–i43. doi:10.1136/qshc.2009.038562 [CrossRef] PMID:20693215
  8. Vukin E, Greenberg R, Auerbach M, et al. Use of simulation-based education: a national survey of pediatric clerkship directors. Acad Pediatr. 2014;14(4):369–374. doi:10.1016/j.acap.2014.04.001 [CrossRef] PMID:24976349
  9. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007;2(2):115–125. doi:10.1097/SIH.0b013e3180315539 [CrossRef] PMID: 19088616
  10. Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013;35(10):e1511–e1530. doi:10.3109/0142159X.2013.818632 [CrossRef] PMID:23941678
  11. Jani P. Achieving your goals with simulation. In: Wild B, McQueen A, Hageman J, Wang E, eds. Pediatric Simulation Handbook. Nova; 2020:chapter 2.
  12. Stocker M, Burmester M, Allen M. Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework [published online ahead of print April 3, 2014]. BMC Med Educ. doi:10.1186/1472-6920-14-69 [CrossRef] PMID:24694243
  13. Calhoun A, Sigalet E, Burns R, Auerbach M. Simulation along the pediatric healthcare education continuum. In: Grant V, Cheng A, eds. Comprehensive Healthcare Simulation: Pediatrics. Springer. 2016;167–179. doi:10.1007/978-3-319-24187-6_13 [CrossRef]
  14. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86(6):706–711. doi:10.1097/ACM.0b013e318217e119 [CrossRef] PMID:21512370
  15. McGaghie WC, Issenberg SB, Barsuk JH, Wayne DB. A critical review of simulation-based mastery learning with translational outcomes. Med Educ. 2014;48(4):375–385. doi:10.1111/medu.12391 [CrossRef] PMID:24606621
  16. Mills DM, Williams DC, Dobson JV. Simulation training as a mechanism for procedural and resuscitation education for pediatric residents: a systematic review. Hosp Pediatr. 2013;3(2):167–176. doi:10.1542/hpeds.2012-0041 [CrossRef] PMID:24340419
  17. McMillan HJ, Writer H, Moreau KA, et al. Lumbar puncture simulation in pediatric residency training: improving procedural competence and decreasing anxiety [published online ahead of print August 8, 2016]. BMC Med Educ. doi:10.1186/s12909-016-0722-1 [CrossRef] PMID:27502925
  18. Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009;37(10):2697–2701. PMID:19885989
  19. White ML, Jones R, Zinkan L, Tofil NM. Transfer of simulated lumbar puncture training to the clinical setting. Pediatr Emerg Care. 2012;28(10):1009–1012. doi:10.1097/PEC.0b013e31826ca96b [CrossRef] PMID:23023465
  20. Joint Commission on Accreditation of Healthcare Organizations. Joint Commission: patient safety initiatives. Accessed January 8, 2021.
  21. Hepps JH, Yu CE, Calaman S. Simulation in medical education for the hospitalist: moving beyond the mock code. Pediatr Clin North Am. 2019;66(4):855–866. doi:10.1016/j.pcl.2019.03.014 [CrossRef] PMID:31230627
  22. Gilfoyle E, Gottesman R, Razack S. Development of a leadership skills workshop in paediatric advanced resuscitation. Med Teach. 2007;29(9):e276–e283. doi:10.1080/01421590701663287 [CrossRef] PMID:18158652
  23. Blackwood J, Duff JP, Nettel-Aguirre A, Djogovic D, Joynt C. Does teaching crisis resource management skills improve resuscitation performance in pediatric residents?Pediatr Crit Care Med. 2014;15(4):e168–e174. doi:10.1097/PCC.0000000000000100 [CrossRef] PMID:24622164
  24. Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med. 2011;12(1):33–38. doi:10.1097/PCC.0b013e3181e89270 [CrossRef] PMID:20581734
  25. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56–61. doi:10.1378/chest.07-0131 [CrossRef] PMID:17573509
  26. Maa T, Scherzer DJ, Harwayne-Gidansky I, et al. PEAK investigators of the International Network for Simulation-based Pediatric Innovation, Research, & Education (INSPIRE). Prevalence of errors in anaphylaxis in kids (PEAK): a multicenter simulation-based study. J Allergy Clin Immunol Pract. 2020;8(4):1239–1246.e3. doi:10.1016/j.jaip.2019.11.013 [CrossRef] PMID:31770652
  27. Brydges R, Campbell DM, Beavers L, et al. Lessons learned in preparing for and responding to the early stages of the COVID-19 pandemic: one simulation's program experience adapting to the new normal [published online ahead of print June 3, 2020]. Adv Simul (Lond). doi:10.1186/s41077-020-00128-y [CrossRef] PMID:32514385
  28. Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19 alternate care site using failure modes and effect analysis with in situ simulation. Anesthesiology. 2020;133(5):985–996. doi:10.1097/ALN.0000000000003521 [CrossRef] PMID:32773686
  29. Center for Medical Simulation. Accessed December 18, 2020.

Components of Medical Simulation

Immersive <list-item>

In situ: within the clinical space/place where care is delivered


Center-based: in a space dedicated to medical simulation with equipment commonly found in clinical spaces


Virtual: computer-based clinical environments with multimedia clinical cues


Skill focused: situationally specific and provides the minimum equipment necessary to practice a specific skill

Experiential <list-item>

Mock code


Standardized patient examination or communication


Procedural skill/intervention


Diagnostic skill/modality

Educational <list-item>

Scenario designed to meet specific learning objectives


The scenario is debriefed <list-item>

The learner reflects on their experience


The learner receives feedback on their performance with respect to the learning objectives



The facilitator provides additional clinical insights and mentorship specific to the learner's needs and questions


Forms of Simulation

Simulator type Characteristics Applications
Human patient Life-size manikins that anatomically and physiologically mimic the human body, including vital signs, physical symptoms (cough, seizure), and allowing for medical procedures such as bag-valve mask ventilation, intubation, and defibrillation Simulation-based medical education curricula Team training or individual training for medical interventions such as:   Trauma   Cardiopulmonary resuscitation   Preparation for surgical emergencies in the operating room Quality improvement Systems safety, functionality, and process testing
Task trainer Partial-body trainers allowing for practice in a particular procedural skill or task. Examples include peripheral intravenous catheter insertion, intubation, and lumbar puncture Simulation-based education curricula Skill acquisition and improved retention through deliberate practice and/or mastery learning
Standardized patients Human beings who are trained actors in the portrayal of patients using an intentionally developed character script Particularly useful for providing education and/or assessment for interpersonal skills, communication skills, professionalism, history-taking, and navigation of challenging conversations such as end-of-life care or delivering bad news Simulation-based medical education (formative) Simulation-based assessment (summative)
Virtual reality A computer-based simulated clinical environment. A newer type of simulator demonstrating promising results for the promotion of cognitive knowledge as well as technical skills Knowledge and skills development Pairing with haptic interfacesallow the learner to simulate procedural skills by linking their hand movements with time, motion, and movement of an object in the virtual environment (ie, a laryngoscope or intravenous needles)

Priti Jani, MD, MPH, is an Assistant Professor of Pediatrics, Section of Critical Care Medicine, The University of Chicago, Comer Children's Hospital. Bridget M. Wild, MD, is a Pediatric Hospitalist, NorthShore University HealthSystem; the Interim Medical Director, Grainger Center for Simulation & Innovation; and a Clinical Assistant Professor, Pritzker School of Medicine.

Address correspondence to Priti Jani, MD MPH, Section of Critical Care Medicine, The University of Chicago, Comer Children's Hospital, 5841 S. Maryland Avenue, L-443, MC 1145, Chicago, IL 60637; email:

Disclosure: The authors have no relevant financial relationships to disclose.


Sign up to receive

Journal E-contents
click me