Richard A. Henson School of Science & Technology

Medical Simulation Center

Selected Studies Supporting Medical Simulation Education

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Aggarwal, R. and A. Darzi (2011). "Simulation to enhance patient safety: why aren't we there yet?" Chest 140(4): 854-858.

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            The delivery of state-of-the-art medical care is complex, with large numbers of treatment strategies often available to individual patients. It is paramount to ensure that each patient receives optimal treatment in a safe, effective, and timely manner. Evidence suggests that an unacceptably high number of patients currently experience suboptimal care as the result of adverse events and medical error. Simulation-based training reduces medical error, enhances clinical outcomes, and reduces the cost of clinical care. It is surprising that medical simulation is not routinely integrated into the training curricula of all health-care professionals. Simulation enables doctors to practice and hone their technical, communication, decision making, and crisis management skills in a safe and educationally orientated environment. The process can foster the development of inter-professional working skills, leading to enhanced patient outcomes. Selection, credentialing, and revalidation of medical professionals are also possible in a simulation setting, enabling maintenance of standards of practice throughout a medical career. In order for simulation to become a part of the medical curriculum, collaborative efforts are required from academics, physicians, managers, and policy makers alike. Bringing these groups together, while a challenge, can lead to high-level outputs in medical care, which will benefit all.

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Barnett, G. V., L. Hollister, et al. (2011). "Use of the Standardized Patient to Clarify Interdisciplinary Team Roles." Clinical Simulation in Nursing 7(5): e169-e173.

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            Background The University of Utah began an interdisciplinary experience for students of the health sciences professions in order to improve communication and experience teamwork. Process Students from different health professions interviewed standardized patients then worked in teams to develop a care plan. Results Students' evaluations of the experience were positive. Students felt more at ease in their communications with other disciplines after the experience. They saw the value of teamwork in giving optimal patient care. Conclusions Interdisciplinary team experiences, such as the one described here, are valuable tools for exposure to the healthcare teamwork needed to improve patient outcomes.

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Blewer, A. L., M. Leary, et al. (2011). "Continuous chest compression cardiopulmonary resuscitation training promotes rescuer self-confidence and increased secondary training: A hospital-based randomized controlled trial." Critical Care Medicine Publish Ahead of Print: 10.1097/CCM.1090b1013e318236f318232ca.

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            Objective: Recent work suggests that delivery of continuous chest compression cardiopulmonary resuscitation is an acceptable layperson resuscitation strategy, although little is known about layperson preferences for cardiopulmonary resuscitation training in continuous chest compression cardiopulmonary resuscitation. We hypothesized that continuous chest compression cardiopulmonary resuscitation education would lead to greater trainee confidence and would encourage wider dissemination of cardiopulmonary resuscitation skills compared to standard cardiopulmonary resuscitation training (30 compressions: two breaths). Design: Prospective, multicenter cohort study. Setting: Three academic medical center inpatient wards. Subjects: Adult family members or friends (>=18 yrs old) of inpatients admitted with cardiac-related diagnoses. Interventions: In a multicenter randomized trial, family members of hospitalized patients were trained via the educational method of video self-instruction. Subjects were randomized to continuous chest compression cardiopulmonary resuscitation or standard cardiopulmonary resuscitation educational modes. Measurements: Cardiopulmonary resuscitation performance data were collected using a cardiopulmonary resuscitation skill-reporting manikin. Trainee perspectives and secondary training rates were assessed through mixed qualitative and quantitative survey instruments. Main Results: Chest compression performance was similar in both groups. The trainees in the continuous chest compression cardiopulmonary resuscitation group were significantly more likely to express a desire to share their training kit with others (152 of 207 [73%] vs. 133 of 199 [67%], p = .03). Subjects were contacted 1 month after initial enrollment to assess actual sharing, or "secondary training." Kits were shared with 2.0 +/- 3.4 additional family members in the continuous chest compression cardiopulmonary resuscitation group vs. 1.2 +/- 2.2 in the standard cardiopulmonary resuscitation group (p = .03). As a secondary result, trainees in the continuous chest compression cardiopulmonary resuscitation group were more likely to rate themselves "very comfortable" with the idea of using cardiopulmonary resuscitation skills in actual events than the standard cardiopulmonary resuscitation trainees (71 of 207 [34%] vs. 57 of 199 [28%], p = .08). Conclusions: Continuous chest compression cardiopulmonary resuscitation education resulted in a statistically significant increase in secondary training. This work suggests that implementation of video self-instruction training programs using continuous chest compression cardiopulmonary resuscitation may confer broader dissemination of life-saving skills and may promote rescuer comfort with newly acquired cardiopulmonary resuscitation knowledge. Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifier: NCT01260441. (C) 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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Cook, D. A., R. Hatala, et al. (2011). "Technology-enhanced simulation for health professions education: a systematic review and meta-analysis." JAMA 306(9): 978-988.

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            CONTEXT: Although technology-enhanced simulation has widespread appeal, its effectiveness remains uncertain. A comprehensive synthesis of evidence may inform the use of simulation in health professions education. OBJECTIVE: To summarize the outcomes of technology-enhanced simulation training for health professions learners in comparison with no intervention. DATA SOURCE: Systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. STUDY SELECTION: Original research in any language evaluating simulation compared with no intervention for training practicing and student physicians, nurses, dentists, and other health care professionals. DATA EXTRACTION: Reviewers working in duplicate evaluated quality and abstracted information on learners, instructional design (curricular integration, distributing training over multiple days, feedback, mastery learning, and repetitive practice), and outcomes. We coded skills (performance in a test setting) separately for time, process, and product measures, and similarly classified patient care behaviors. DATA SYNTHESIS: From a pool of 10,903 articles, we identified 609 eligible studies enrolling 35,226 trainees. Of these, 137 were randomized studies, 67 were nonrandomized studies with 2 or more groups, and 405 used a single-group pretest-posttest design. We pooled effect sizes using random effects. Heterogeneity was large (I(2)>50%) in all main analyses. In comparison with no intervention, pooled effect sizes were 1.20 (95% CI, 1.04-1.35) for knowledge outcomes (n = 118 studies), 1.14 (95% CI, 1.03-1.25) for time skills (n = 210), 1.09 (95% CI, 1.03-1.16) for process skills (n = 426), 1.18 (95% CI, 0.98-1.37) for product skills (n = 54), 0.79 (95% CI, 0.47-1.10) for time behaviors (n = 20), 0.81 (95% CI, 0.66-0.96) for other behaviors (n = 50), and 0.50 (95% CI, 0.34-0.66) for direct effects on patients (n = 32). Subgroup analyses revealed no consistent statistically significant interactions between simulation training and instructional design features or study quality. CONCLUSION: In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.

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Frengley, R. W., J. M. Weller, et al. (2011). "The effect of a simulation-based training intervention on the performance of established critical care unit teams." Crit Care Med 39(12): 2605-2611.

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            OBJECTIVE: : We evaluated the effectiveness of a simulation-based intervention on improving teamwork in multidisciplinary critical care teams managing airway and cardiac crises and compared simulation-based learning and case-based learning on scores for performance. DESIGN: : Self-controlled randomized crossover study design with blinded assessors. SETTING: : A simulated critical care ward, using a high-fidelity patient simulator, in a university simulation center. SUBJECTS: : Forty teams from critical care units within the region comprising one doctor and three nurses. INTERVENTION: : At the beginning and end of the 10-hr study day, each team undertook two pre-intervention and two post-intervention assessment simulations (one airway, one cardiac on both occasions). The study day included presentations and discussions on human factors and crisis management, and airway and cardiac skills stations. For the intervention, teams were randomized to case-based learning or simulation-based learning for cardiac or airway scenarios. MEASUREMENTS AND MAIN RESULTS: : Each simulation was recorded and independently rated by three blinded expert assessors using a structured rating tool with technical and behavioral components. Participants were surveyed 3 months later. We demonstrated significant improvements in scores for overall teamwork (p </= .002) and the two behavioral factors, "Leadership and Team Coordination" (p </= .002) and "Verbalizing Situational Information" (p </= .02). Scores for clinical management also improved significantly (p </= .003). We found no significant difference between simulation-based learning and case-based learning in the context of this study. Survey data supported the effectiveness of study day with responders reporting retention of learning and changes made to patient management. CONCLUSIONS: : A simulation-based study day can improve teamwork in multidisciplinary critical care unit teams as measured in pre- and post-course simulations with some evidence of subsequent changes to patient management. In the context of a full-day course, using a mix of simulation-based learning and case-based learnings seems to be an effective teaching strategy.

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Nishisaki, A., J. Nguyen, et al. (2011). "Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit." Pediatr Crit Care Med 12(4): 406-414.

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            OBJECTIVE: Tracheal intubation in the pediatric intensive care unit is often performed in emergency situations with high risks. Simulation has been recognized as an effective methodology to train both technical and teamwork skills. Our objectives were to develop a feasible tool to evaluate team performance during tracheal intubation in the pediatric intensive care unit and to apply the tool in the clinical setting to determine whether multidisciplinary teams with a higher number of simulation-trained providers exhibit more proficient performance. DESIGN: Prospective, observational pilot study. SETTING: Single tertiary children's hospital pediatric intensive care unit. SUBJECTS: Pediatric and emergency medicine residents, pediatric intensive care unit nurses, and respiratory therapists from October 2007 to June 2008. INTERVENTIONS: A pediatric intensive care unit on-call resident, a pediatric intensive care unit nurse, and a respiratory therapist received simulation-based multidisciplinary airway management training every morning. An assessment tool for team technical and behavioral skills was developed. Independent trained observers rated actual intubations in the pediatric intensive care unit by using this tool. MEASUREMENTS AND MAIN RESULTS: For observer training, two independent raters (research assistants 1 and 2) evaluated a total of 53 training sessions (research assistant 1, 16; research assistant 2, 37). The correlation coefficient with the facilitator expert (surrogate standard) was .73 for research assistant 1 and .88 for research assistant 2 (p </= .001 for both) in the total score, .84 for research assistant 1 and .77 for research assistant 2 (p < .001 for both) in the technical domain, and .63 for research assistant 1 (p = .009) and .84 for research assistant 2 (p < .001) in the behavioral domain. The correlation coefficient was lower in video-based observation (.62 vs. .88, on-site). For clinical observation, 15 intubations were observed in real time by raters. The performance by a team with two or more simulation-trained members was rated higher compared with the team with fewer than two trained members (total score: 127 +/- 6 vs. 116 +/- 9, p = .012, mean +/- sd). CONCLUSIONS: It is feasible to rate the technical and behavioral performance of multidisciplinary airway management teams during real intensive care unit intubation events by using our assessment tool. The presence of two or more multidisciplinary simulation-trained providers is associated with improved performance during real events.

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Passiment, M., H. Sacks, et al. (2011). "Medical Simulation in Medical Education: Results of an AAMC Survey."

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            The AAMC, working jointly with the Society for Simulation in Healthcare (SSH), the Association for Standardized Patient Educators (ASPE), and the American Association of Colleges of Nursing (AACN) developed the survey in 2010 to better understand how medical schools and teaching hospitals are using simulation for education and assessment and determine the operational impact of simulation at AAMC-member institutions. The survey data demonstrates medical schools and teaching hospitals are exploring and adopting simulation as an avenue to enhance learning at all stages of the medical education continuum.

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Zhang, C., S. Thompson, et al. (2011). "A Review of Simulation-Based Interprofessional Education."  7(4): e117-e126.

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            Simulation is fast becoming an integral part of health professional education, including interprofessional education (IPE). There are numerous reports of positive student reactions to this innovative teaching strategy. However, there remains a need for evidence of positive learning outcomes from studies using methodological rigor and validated evaluation strategies. The purpose of this literature review and synthesis is to examine research studies of simulation-based interprofessional education (IPE), with a focus on study design and evaluation strategies. A literature search was conducted using CINAHL, MEDLINE, and PsycINFO for the years 1999–2009. A total of 25 studies met the established inclusion criteria, namely, (a) both simulation and IPE were reported, (b) research study results were presented, and (c) quantitative assessment and /or outcome measures were reported. Although positive effects of simulation-based IPE were revealed, a wide range of educational interventions used outcome measures that were investigator-developed questionnaires lacking psychometric testing. Given these findings, the authors suggest that the use of an evaluation framework that defines outcomes and a quality improvement model to structure a disciplined approach to designing and testing an intervention could provide the scientific foundation for measuring effectiveness of simulation-based IPE.

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Lighthall, G. K., T. Poon, et al. (2010). "Using In Situ Simulation to Improve In-Hospital Cardiopulmonary Resuscitation." Joint Commission Journal on Quality and Patient Safety 36(5): 209-216.

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            Background: There is widespread recognition that the conduct of cardiac resuscitation is problematic. In situ simulation has been used to train and evaluate cardiac arrest teams' performance in the hospital setting, but in work at a university-affiliated, tertiary care facility, the simulated cardiac arrests were used to understand how well health care providers and their environment function during arrests, with the goal of a rapid intervention to correct problem areas. Latent conditions&#8212;innate, mostly hidden, workplace factors&#8212;can have a large detrimental impact on resuscitation efforts.<P></P><B>Methods:</B> Observations from a series of unannounced simulated cardiac arrests undertaken at diverse locations within a university-affiliated, tertiary care hospital were a component of an ongoing initiative to improve performance of emergency cardiovascular care.<P></P><B>Results:</B> Fourteen cardiac arrest simulations revealed 24 hazardous findings, approximately two thirds of which had a high likelihood of compromising patient survival if they had occurred during an actual cardiac arrest. Categories of problems included active errors by teams and individuals and systemic or latent errors of the environment. Because the simulations were designed with the goal of discovering and documenting errors, most errors led to further actions, policies, and procedures that were rapidly adopted by the medical center to prevent their recurrence.<P></P><B>Conclusions:</B> In situ simulation of cardiac arrests elicits lifelike behaviors and allows engagement of all personnel and resources applicable to real arrests. This method allowed for remedial plans to be developed before further harm could occur. Accordingly, in situ simulation of high-risk events may be a useful, efficient technique that complements existing quality assurance processes in hospitals.

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Ruesseler, M., M. Weinlich, et al. (2010). "Simulation training improves ability to manage medical emergencies." Emerg Med J 27(10): 734-738.

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            OBJECTIVE: In the case of an emergency, fast and structured patient management is crucial for a patient's outcome. Every physician and graduate medical student should possess basic knowledge of emergency care and the skills to manage common emergencies. This study determines the effect of a simulation-based curriculum in emergency medicine on students' abilities to manage emergency situations. METHODS: A controlled, blinded educational trial of 44 final-year medical students was carried out at Frankfurt Medical School; 22 students completed the former curriculum as the control group and 22 the new curriculum as the intervention group. The intervention consists of simulation-based training with theoretical and simulation-based training sessions in realistic encounters based on the Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and adapted Advanced Trauma Life Support (ATLS) training. Further common emergencies were integrated corresponding to the course objectives. All students faced a performance-based assessment in a 10 station Objective Structured Clinical Examination (OSCE) using checklist rating within a maximum of 4 months after completion of the intervention. RESULTS: The intervention group performed significantly better at all of the 10 OSCE stations in the checklist rating (p<0.0001 to p=0.016). CONCLUSIONS: The simulation-based intervention offers a positively evaluated possibility to enhance students' skills in recognising and handling emergencies. Additional studies are required to measure the long-term retention of the acquired skills, as well as the effect of training in healthcare professionals.

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Barsuk, J. H. (2009). "Use of Simulation-Based Education to Reduce Catheter-Related Bloodstream Infections." Archives of Internal Medicine 169(15): 1420-1423.

            Background:  Simulation-based education improves procedural competence in central venous catheter (CVC) insertion. The effect of simulation-based education in CVC insertion on the incidence of catheter-related bloodstream infection (CRBSI) is unknown. The aim of this study was to determine if simulation-based training in CVC insertion reduces CRBSI. Methods:  This was an observational education cohort study set in an adult intensive care unit (ICU) in an urban teaching hospital. Ninety-two internal medicine and emergency medicine residents completed a simulation-based mastery learning program in CVC insertion skills. Rates of CRBSI from CVCs inserted by residents in the ICU before and after the simulation-based educational intervention were compared over a 32-month period. Results:  There were fewer CRBSIs after the simulator-trained residents entered the intervention ICU (0.50 infections per 1000 catheter-days) compared with both the same unit prior to the intervention (3.20 per 1000 catheter-days) (P = .001) and with another ICU in the same hospital throughout the study period (5.03 per 1000 catheter-days) (P = .001). Conclusions:  An educational intervention in CVC insertion significantly improved patient outcomes. Simulation-based education is a valuable adjunct in residency education.

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Dieckmann, P., S. Molin Friis, et al. (2009). "The art and science of debriefing in simulation: Ideal and practice." Medical teacher 31(7): e287-294.

            OBJECTIVES: Describing what simulation centre leaders see as the ideal debriefing for different simulator courses (medical vs. crisis resource management (CRM)-oriented). Describing the practice of debriefing based on interactions between instructors and training participants. METHODS: Study 1 - Electronic questionnaire on the relevance of different roles of the medical teacher for debriefing (facilitator, role model, information provider, assessor, planner, resource developer) sent to simulation centre leaders. Study 2 - Observation study using a paper-and-pencil tool to code interactions during debriefings in simulation courses for CRM for content (medical vs. CRM-oriented) and type (question vs. utterance). RESULTS: Study 1 - The different roles were seen as equally important for both course types with the exception of 'information provider' which was seen as more relevant for medical courses. Study 2 - There were different interaction patterns during debriefings: line - involving mostly the instructor and one course participant, triangle - instructor and two participants, fan - instructor and all participants in a dyadic form and net - all participants and the instructor with cross references. CONCLUSION: What simulation centre heads think is important for the role mix of simulation instructors is (at least partly) not reflected in debriefing practice.

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Wayne, D. B., A. Didwania, et al. (2008). "Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study." Chest 133(1): 56-61.

            BACKGROUND: Simulation technology is widely used in medical education. Linking educational outcomes achieved in a controlled environment to patient care improvement is a constant challenge. METHODS: This was a retrospective case-control study of cardiac arrest team responses from January to June 2004 at a university-affiliated internal medicine residency program. Medical records of advanced cardiac life support (ACLS) events were reviewed to assess adherence to ACLS response quality indicators based on American Heart Association (AHA) guidelines. All residents received traditional ACLS education. Second-year residents (simulator-trained group) also attended an educational program featuring the deliberate practice of ACLS scenarios using a human patient simulator. Third-year residents (traditionally trained group) were not trained on the simulator. During the study period, both simulator-trained and traditionally trained residents responded to ACLS events. We evaluated the effects of simulation training on the quality of the ACLS care provided. RESULTS: Simulator-trained residents showed significantly higher adherence to AHA standards (mean correct responses, 68%; SD, 20%) vs traditionally trained residents (mean correct responses, 44%; SD, 20%; p = 0.001). The odds ratio for an adherent ACLS response was 7.1 (95% confidence interval, 1.8 to 28.6) for simulator-trained residents compared to traditionally trained residents after controlling for patient age, ventilator, and telemetry status. CONCLUSIONS: A simulation-based educational program significantly improved the quality of care provided by residents during actual ACLS events. There is a growing body of evidence indicating that simulation can be a useful adjunct to traditional methods of procedural training.

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Rudolph, J. W., R. Simon, et al. (2007). "Debriefing with good judgment: combining rigorous feedback with genuine inquiry." Anesthesiology clinics 25(2): 361-376.

            Drawing on theory and empirical findings from a 35-year research program in the behavioral sciences on how to improve professional effectiveness through reflective practice, we develop a model of "debriefing with good judgment." The model specifies a rigorous reflection process that helps trainees surface and resolve pressing clinical and behavioral dilemmas raised by the simulation. Based on the authors' own experience using this approach in approximately 2000 debriefings, it was found that the "debriefing with good judgment" approach often sparks self-reflection and behavior change in trainees.

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Issenberg, S. B., W. C. McGaghie, et al. (2005). "Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review." Medical teacher 27(1): 10-28.

            REVIEW DATE: 1969 to 2003, 34 years. BACKGROUND AND CONTEXT: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. OBJECTIVES: Review and synthesize existing evidence in educational science that addresses the question, 'What are the features and uses of high-fidelity medical simulations that lead to most effective learning?'. SEARCH STRATEGY: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the 'grey literature' were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. INCLUSION AND EXCLUSION CRITERIA: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. DATA EXTRACTION: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. DATA SYNTHESIS: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. HEADLINE RESULTS: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following: providing feedback--51 (47%) journal articles reported that educational feedback is the most important feature of simulation-based medical education; repetitive practice--43 (39%) journal articles identified repetitive practice as a key feature involving the use of high-fidelity simulations in medical education; curriculum integration--27 (25%) journal articles cited integration of simulation-based exercises into the standard medical school or postgraduate educational curriculum as an essential feature of their effective use; range of difficulty level--15 (14%) journal articles address the importance of the range of task difficulty level as an important variable in simulation-based medical education; multiple learning strategies--11 (10%) journal articles identified the adaptability of high-fidelity simulations to multiple learning strategies as an important factor in their educational effectiveness; capture clinical variation--11 (10%) journal articles cited simulators that capture a wide variety of clinical conditions as more useful than those with a narrow range; controlled environment--10 (9%) journal articles emphasized the importance of using high-fidelity simulations in a controlled environment where learners can make, detect and correct errors without adverse consequences; individualized learning--10 (9%) journal articles highlighted the importance of having reproducible, standardized educational experiences where learners are active participants, not passive bystanders; defined outcomes--seven (6%) journal articles cited the importance of having clearly stated goals with tangible outcome measures that will more likely lead to learners mastering skills; simulator validity--four (3%) journal articles provided evidence for the direct correlation of simulation validity with effective learning. CONCLUSIONS: While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.

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