title: In situ simulation: identification of systems issues.
abstract: The Institute of Medicine's report, To Err is Human, concluded that "medical errors are not a result of isolated individual actions but rather faulty systems, processes, and conditions that lead people to make mistakes." In situ simulation offers the unique opportunity to train the teams of people who deliver healthcare while enhancing policies, evaluating new technologies, and improving the systems that support the delivery of safe healthcare. For this reason, the Institute of Medicine, the Joint Commission, and the Agency for Healthcare Research and Quality recommend medical simulation as one of the most important safe practice interventions to reduce errors and risks associated with the process of care. This review builds on other reports in this issue and discusses the application of in situ simulation to identify, address, and test systems improvements.
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, mail code L466, 3181 SW Sam Jackson Pk Rd, Portland, OR 97239-3098, USA. guisej@ohsu.edu
authors.forename: Jeanne-Marie
authors.initials: JM
authors.lastname: Guise
authors.forename: Jeanette
authors.initials: J
authors.lastname: Mladenovic
mesh_terms: D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D009774:Obstetrics / Q000458:organization & administration / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care; D016544:Patient Simulation; D011247:Pregnancy; D058996:Quality Improvement / Q000458:organization & administration*; D011787:Quality of Health Care / Q000592:standards*; D014481:United States