In this article, we explore 3 examples of how hospitals used in situ simulation to drive quality improvement in the NICU and protect the safety of their most vulnerable patients. 

Patients in the Neonatal Intensive Care Unit (NICU) are uniquely vulnerable due to their stage in physical development and the complexity of their care. In this specialized environment, the stakes of medical error are uniquely high. 
 
Traditionally, improvement efforts have focused on individual performance. This can have positive results in the short term. But if it is the only solution, improvement efforts easily plateau, leading to potential burnout, emotional exhaustion, compassion fatigue, and even moral distress as staff identify needed changes but feel unable to act.

In light of this, NICU leaders, risk managers, and quality professionals are increasingly recognizing that most adverse events are not caused by a single clinician, but by system failures. 

“Even the best-trained team cannot deliver top-tier care in a suboptimal environment.”¹   

- Dr. Jens-Christian Schwindt, 
Neonatologist

Before We Begin: A New Trend in Simulation

This new understanding that "systems failure", or failure in how work gets done rather than failure by who does the work, has fueled the adoption of a new paradigm in simulation: translational simulation.

Translational simulation is the use of simulation to identify, test, and improve real-world clinical systems, processes, and environments to improve quality and outcomes. 
 
A fundamental element of translational simulation is the use of in situ simulation, or simulation that occurs in the actual clinical environment. By testing “work as done,” rather than “work as imagined,” in situ simulation helps uncover latent safety threats (LSTs). 
 
Commonly referred to as “accidents waiting to happen,” LSTs are hidden vulnerabilities in equipment, environment, or processes. These vulnerabilities may remain unnoticed until they contribute to patient harm. 
 
“What makes in situ simulation so powerful is that it allows medical teams to train right where it matters most: in their own clinical environment, under real-world conditions,”² explains Dr. Jens-Christian Schwindt, Neonatologist.  

Example 1: Uncovering Hidden Vulnerabilities in the Resuscitation Environment

A multicenter study of neonatal resuscitation across was conducted across nine Austrian hospitals using a series of interdisciplinary in situ simulations.³ Their goal was to identify LSTs in the initial simulations and test whether those LSTs reoccurred or had been resolved in follow-up simulations.  

To achieve a high level of realism, the study used SimNewB^®: a newborn, tetherless simulator ideal for in situ training.  

A total of 400 latent safety threats were identified across the simulations, in areas including: 

In the systems, pathways, and resources category, they saw a lower reduction in LSTs: a 10% decrease from one simulation to the next. This finding suggested that issues in this category were more challenging to solve, and would require more time and resources to mitigate. 
 
Ultimately, this study emphasizes simulation’s effectiveness in uncovering, reducing, and resolving LSTs over time.  

Example 2: Stress-Testing a Critical Move

A large children’s hospital needed to transfer 70 critically ill neonates to a new Critical Care building.⁴ To prepare, they used simulation to test every detail of their move plan so they could mitigate risk before the first patient was transported. 
 
They conducted six intensive simulation sessions, during which they simulated moving the NICU patients from the original unit to the new unit. The teams identified key vulnerabilities and mitigated them successfully: 

The results were extraordinary: all 70 patients were moved safely in 6.5 hours — almost half the projected time. There were zero safety events or code activations. 
 
This study demonstrates how simulation-based systems testing can ensure operational readiness before real-world transitions.  

Example 3: Sustaining Patient Safety Through Continuous Collaboration

A fundamental benefit of using simulation is that it brings people together in the problem solving process. A long-term, eight-year study examined how regular in situ simulations influenced LSTs in a regional hospital’s NICU.⁵ Thirteen interdisciplinary sessions were conducted, engaging anesthesiologists, obstetricians, midwives, nurses, and pediatricians.

The simulations uncovered 67 latent safety threats, including:

• Equipment issue: ECG electrodes not connected to monitors and inactive devices were corrected through improved protocols
• Equipment issue: suction container at the resuscitation table was too small
• Protocol issue: Outdated resuscitation algorithms were replaced to align with current evidence-based guidelines. 

The impact was clear:

When the in situ simulation program was paused during the COVID-19 pandemic, latent threats surged again. This provides proof that ongoing simulation is essential for sustaining patient safety. 

Ready to try in situ simulation to drive quality improvement in your NICU? Here are 3 tips to get started. 

We’re doing some exciting things in the field of Healthcare Quality Improvement. Follow our Healthcare Quality Improvement hub page for more resources, and be sure to speak with one of our Laerdal representatives to see how we can help you in your efforts.