• malpractice;
  • patient simulation;
  • graduate education;
  • legal liability;
  • legislation and jurisprudence;
  • medical errors


Objectives:  The authors present a novel approach to the use of simulation in medical education with a two-event layered simulation. A patient care simulation with an adverse outcome was followed by a simulated deposition.

Methods:  Senior residents in an academic emergency medicine (EM) program were solicited as simulation research volunteers. Other than stating that the research involved adverse outcomes, no identifying information was given. Seven volunteers participated in a simulation involving a forced error (nurse confederate gave an incorrect medication dose). Six weeks later based on the initial simulation, one physician completed a simulated deposition in a teaching conference conducted by a licensed attorney with malpractice experience. The audience, consisting of residents, attendings, and students, watched a recording of the patient care, witnessed the deposition, and evaluated the experience using a 17-question survey with 5-point Likert scales.

Results:  Participants felt that overall the training program was a useful educational tool (mean ± standard deviation [SD] Likert score = 4.63 ± 0.49) that would change aspects of their practice (3.31 ± 0.85). Participants stated that they would be more careful in their documentation (3.88 ± 0.60), review high-risk situations with staff (4.00 ± 0.71), and monitor more carefully for errors (3.95 ± 0.74). There was increased fear of the litigation process (3.95 ± 1.18), but participants felt the experience would help improve the risk profile of their practices (3.71 ± 0.68).

Conclusions:  A novel approach to medical education was successful in changing attitudes and provided an expanded educational experience for participants. Layered simulation can be successfully incorporated into educational programs for numerous issues including medical malpractice.