MH simulation toolkit

Major haemorrhage is a time-critical emergency that demands rapid, coordinated, and accurate responses across multiple departments. Failures in communication, delays in blood availability, and fragmented processes are well-recognised contributors to avoidable harm.

The UK Patient Safety Alert (CAS Alert NHS/PSA/RE/2020/001) highlighted these risks, calling on all hospitals to implement regular simulation training to strengthen preparedness and reduce the likelihood of errors. Reports from the Serious Hazards of Transfusion (SHOT) and national audits have consistently demonstrated that delays in transfusion, miscommunication, and gaps in laboratory or logistical support directly impact patient morbidity and mortality.

The educational value of simulation in major haemorrhage management is well established. Studies in the UK have shown that simulation significantly improves junior doctors’ knowledge of major haemorrhage protocols compared with traditional training. However, skills decay rapidly without reinforcement; performance in both technical and cognitive tasks has been shown to decline within months if practice is not maintained. This highlights the need for structured, regular, and inclusive simulation-based training.

Simulation is an enhanced learning experience that replicates real-life situations and scenarios providing healthcare professionals the opportunity to refine their skills in a safe environment. It enables healthcare professionals to practice essential techniques such as surgery, patient care, and emergency management in a risk-free environment while fostering collaboration, effective communication, and teamwork. By simulating real-life medical situations, simulations can enhance patient safety without any risk to actual patients.

Simulation training can take many different forms, each offering unique advantages depending on the learning objectives and available resources. From highly realistic live scenarios to innovative digital technologies such as virtual and augmented reality, these approaches allow healthcare teams to practise technical and non-technical skills in safe but engaging environments. Understanding the different types of simulation training available helps educators select the most appropriate method to meet the needs of learners and the clinical context. Here we present a range of simulation methods that are available, with some methods being more suited to enhance training in major haemorrhage settings than others.

High-Fidelity Simulation

High-fidelity simulation uses advanced manikins or immersive technologies to replicate realistic physiological responses and clinical environments. It can be delivered in two ways:

Classroom-Based High-Fidelity Simulation: Conducted in simulation centres or dedicated training facilities, this method allows teams to practise complex clinical skills using state-of-the-art manikins that can simulate breathing, circulation, and other physiological functions. It is particularly valuable for rehearsing technical procedures such as airway management, vascular access, and blood administration, as well as for developing communication and leadership skills in a controlled environment.

In-Situ High-Fidelity Simulation: This form of simulation uses the same state-of-the-art manikins but takes place in the actual clinical environment such as theatres, emergency departments, or maternity units and is especially powerful for testing systems as well as staff. By using realistic equipment and clinical spaces, in-situ simulation helps teams identify latent safety threats such as equipment availability, communication breakdowns, and logistical barriers that may not be apparent in a classroom setting.

Mock scenario-based learning

Mock scenario-based learning involves the enactment of structured case studies that mirror real-life clinical situations. Unlike high-fidelity simulations, these do not necessarily require advanced manikins or complex technology. Instead, they rely on carefully designed scenarios and role-playing to provide hands-on learning opportunities in a controlled setting. This approach helps bridge the gap between theory and practice, reinforcing clinical knowledge, teamwork, and communication skills without the need for highly technical equipment.

Virtual Reality (VR) Simulation

VR simulation immerses participants in interactive, three-dimensional environments, usually accessed through a headset. This method allows learners to explore clinical scenarios in a fully digital space where they can practise procedures, rehearse decision-making, and respond to emergencies. VR provides high levels of immersion and standardisation while reducing reliance on physical resources, making it particularly useful for remote training or situations where access to simulation centres is limited.

Augmented Reality (AR) Simulation

AR simulation overlays digital information onto the physical environment, enriching the learning experience by combining real-world equipment with computer-generated guidance. For example, AR can provide visual prompts or highlight equipment during transfusion practice, helping staff understand processes step-by-step. By blending theoretical knowledge with practical application, AR promotes skill retention and confidence. It also allows for contextualised training in live clinical environments, supporting learners to translate knowledge directly into practice.

Effective simulation is built on a set of key design and delivery principles that ensure training is both realistic and impactful. These elements help create a structured learning environment where participants can practise safely, receive feedback, and refine their skills. By combining technical accuracy with opportunities for teamwork, reflection, and adaptation, these features maximise the value of simulation and support the transfer of learning into real clinical practice:

• Realistic and Safe Simulations – provide immersive, risk-free environments that ensure emotional support  that mirror real-world conditions
• Interactive and Immersive Tools – use VR/AR and model-based learning for active engagement
• Adaptive and Scenario-Based Learning – tailor and vary scenarios to learner skill levels and organisational goals
• Collaborative Role-Play – foster teamwork and realistic decision-making through defined roles
• Preparation – ensure clear practical learning objectives before sessions to bridge the gap between theory and practice
• Feedback and Continuous Improvement – deliver real-time feedback, metrics, and iterative practice opportunities
• Debriefing and Reflection – use structured discussions to analyse performance and reinforce learning

Rationale: Provision of blood components and products during emergencies. Simulation drills test lab communication, provision of emergency/group specific/cross-matched red cells as well as other blood components and products upon activation of the major haemorrhage protocol (MHP)

Responsibilities

• Team coordination
• Contribute to the design of the simulation planning
• Response times
• Component support until stood down
• Communication
• Be part of and actively contribute to the clinical debrief post event

Rationale: Lead education and simulation delivery. Ensure clinical teams are prepared.

Responsibilities:

• Design and deliver simulation scenarios in alignment with current guidance
• Liaise with key personnel during the planning (e.g. Laboratory teams, Haematologists, Portering Managers)
• Conduct structured debriefs and support team reflection and learning
• Provide a report for the Clinical governance and/or Patient Safety Committee on the number of simulation sessions that occurred and participant feedback

Rationale: Contribute to decision making in emergency situations

Responsibilities

• Team-based communication, activation of MH, management of patient
• Need for Resident Doctors to be involved with consultant support
• Be part of the clinical debrief post event

Rationale: Provide expert advice on complex transfusion decisions and use of specific blood components/products/haemostatic agents (e.g. fibrinogen, tranexamic acid) where required

Responsibilities

• Expert guidance
• Support
• May join debriefings or simulation planning sessions.

Rationale: Support, team coordination, and documentation

Responsibilities

• Simulation inclusion ensures full MDT understanding of situational needs
• Documentation

This will depend on the specific setting, scenario, and staff availability

Rationale: Lead resuscitation, management of patient

Responsibilities

• Lead resuscitation
• Team-based communication
• Safe blood administration
• Advice on the use of specific blood components or products
• Documentation
• Be part of the clinical debrief post event

Rationale: Early recognition of deteriorating patient, activation of MH, team coordination, and documentation

Responsibilities

• Identification of deteriorating patient
• Escalation
• Blood collection from satellite fridges/laboratory
• Safe blood administration
• Documentation
• Be part of the clinical debrief post event

Rationale:  Support, team coordination, and documentation

Responsibilities

• Blood collection from satellite fridge
• Prepare equipment
• Partake in blood component pre-administration checks
• Be part of the clinical debrief post event
• Administer blood components if they are suitably trained and competent and has been locally agreed within their scope of practice

Rationale: Role in safe and timely collection and delivery of blood components. Ensure efficient delivery of emergency/group specific/cross-matched red cells as well as other blood components after activation of the major haemorrhage protocol (MHP)

Responsibilities

• Collections/delivery of urgent samples/blood components
• Response times
• Be part of the clinical debrief post event

Rationale: Ensure safe transfusion practice, identify risks, and reinforce compliance with guidelines and recommendations to reduce patient harm and drive quality improvement.

Responsibilities

• Provide expert input into clinical transfusion simulation scenario planning in conjunction with the Clinical Educators / Simulation Facilitators
• Liaise with key personnel during the planning (e.g. Laboratory teams, Haematologists, Portering Managers)
• Provide feedback/debrief at the simulation session
• Trend MHP events within the organisation, reporting delays (in conjunction with local reporting systems to SHOT) and focusing on key areas for simulation training in conjunction with the Clinical Educators / Simulation Facilitators based on this data
• Offer follow up education if gaps are identified
• Provide a report for the Hospital Transfusion Committee on the number of simulation sessions that occurred and participant feedback

Skills acquired through simulation-based training can deteriorate significantly within 6 to 12 months without reinforcement. Evidence suggests that low-dose, high-frequency (LDHF) training (short, repeated sessions) is more effective in sustaining performance over time compared with infrequent, high-intensity events. For this reason, at a minimum, major haemorrhage (MH) simulation training should be delivered annually. However, biannual or even quarterly sessions are preferable in high-risk or high-turnover environments such as obstetrics, trauma, emergency departments, and theatres.

Smaller-scale drills, including tabletop exercises or virtual simulations, can be used to complement full-scale events and help maintain readiness between larger training sessions. The Defence Medical Services (UK) recommend frequent and realistic MH simulations across all transfusion-capable sites, reflecting the rare but critical nature of MH and the challenges of frequent staff turnover .

In-situ, multidisciplinary simulations have also been shown to improve adherence to MH protocols, strengthen communication, and increase team confidence in decision-making. Whenever possible, simulations should therefore be performed in the actual clinical environment, where they are best placed to reveal system-level issues and test real-world workflows.

Debriefing is a structured and psychologically safe discussion following the simulation. It helps teams explore what occurred, why it happened, and what could be improved. Effective debriefs uncover communication gaps, process breakdowns, or latent threats that may not be apparent during the event.

Best Practices:

• Use structured models (e.g., PEARLS – Promote Excellence and Reflective Learning in Simulation link)
• Focus on systems, not individuals
• Include all participants: clinical, laboratory, and portering staff
• Consider video-assisted debriefing for deeper reflection
• Have an experienced facilitator or simulation educator lead the session

There are several debriefing frameworks available; one is highlighted in the toolkit as an example, but this does not imply it is superior to others. Participants are encouraged to explore different options, as the key is to use a structured format and maintain an inclusive approach

Auditing allows teams to quantify the outcomes of the simulation and identify both clinical and system related performance indicators. By comparing outcomes to national standards, local protocols, or benchmarks, simulation can reveal critical areas for service improvement.

Key Metrics to Consider:

• Time from MH protocol activation to blood issue
• Time taken to deliver blood to the bedside
• Lab turnaround time for group & screen or crossmatch
• Number and types of communication delays or errors
• Use of correct blood component for the clinical indication

The ultimate goal of simulation is to drive change in behaviour, policy, workflow, and system design. After identifying issues through debrief and audit, concrete steps should be taken to improve practice and prevent harm.

Action Steps:

• Revise or update SOPs or MH protocols based on findings
• Deliver focused re-training or skill refreshers if gaps are identified
• Share lessons learnt via safety bulletins, governance meetings, or internal newsletters
• Track implementation of changes and re-audit if needed
• Engage patient safety teams or quality improvement leads for broader support