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KidSIM Simulation Session Activity Report

1. KidSIM Simulation Session Activity Report

Question Title

* 1. Simulation Session Date

Please enter Simulation Session Date

Date

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* 2. Program/Department

Other (please specify)

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* 3. Name of session - as per booking (ie. UIPE, PALS, GNO, etc)

Other (please specify)

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* 4. Was the simulation session inter-professional?

Yes

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* 5. Please list number of participants for each discipline (if number is zero please leave blank)

Staff MD

Fellow

Resident

Medical Student

Nurse Practitioner

LPN

Health Care Aide

Nursing Student

Paramedic/EMT

EMS Student

RT Student

Family Member

School Teacher

Bus Driver

Housekeeping

Security

Pharmacy

Other

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* 6. What type of session took place?

In-Situ (Within clinical practice area)

Simulation Lab

Mobile

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* 7. Site

mobile/other (please specify)

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* 8. Length of session (in hours)
ie. a session that took place from 09:00-11:30 would be 2.5

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* 9. Number of labs running concurrently (at same time)

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* 10. Name of Facilitator(s):

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* 11. Were any of the following standardized elements included in the scenario?
Check all that apply.

2 client identifiers

Connect Care Computers

Critical language tools (e.g ARC)

Dangerous abbreviations

Emergency management codes (ie. Code Blue)

Fall prevention

Family member supporting the patient (spiritual/ cultural practices, self care, etc)

Hand Hygiene

Handover

Hazard identification/ RLS

IV line verification

Medication safety

N/A

Narcotic Safety

RLS reporting discussed

Safe surgical checklist

Structured communication (SBAR, NOD)

The process of disclosure of harm

Other (please specify)

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* 12. Were there any safety concerns identified in the simulation?

Yes

please give a brief description

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* 13. Simulator used? (see ankle bracelet for color and age of manikin)
Check all that apply.

Gaumard Premie (yellow)

Gaumard Newborn (blue)

Gaumard Newborn (red)

Gaumard Toddler (yellow)

Gaumard Toddler (blue)

Gaumard Toddler (red)

Gaumard Child (yellow)

Gaumard Child (blue)

Gaumard Child (red)

Simbaby (yellow)

Simbaby (red)

Laerdal 1 Year Old (blue)

Sim Junior Child (yellow)

Sim Junior Child (blue)

Sim Junior Child (red)

SimMan 3G

CCAN Toddler

SimBaby (PICU)

None

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* 14. Task trainer used?
Check all that apply.

Resusci Anne QCPR

Little Anne QCPR

Resusci Jr QCPR

Little Jr QCPR Full Body

Little Jr QCPR Torso

Little Baby QCPR

Airway head

None

Other (please specify - ie. chest tube model, LP or IV model, trauma head, etc)

Question Title

* 15. Equipment used?
Check all that apply.

Zoll defibrillator

C-Mac

AED trainer

None

Other (please specify)

Question Title

* 16. Were there any issues with mannequins or other equipment?
Please also identify on exit checklist in the lab

Yes

please describe the issue and if it had any impact on training

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50% of survey complete.

Question Title

* 1. Simulation Session Date

Question Title

* 2. Program/Department

Question Title

* 3. Name of session - as per booking (ie. UIPE, PALS, GNO, etc)

Question Title

* 4. Was the simulation session inter-professional?

Question Title

* 5. Please list number of participants for each discipline (if number is zero please leave blank)

Question Title

* 6. What type of session took place?

Question Title

* 7. Site

Question Title

* 8. Length of session (in hours)ie. a session that took place from 09:00-11:30 would be 2.5

Question Title

* 9. Number of labs running concurrently (at same time)

Question Title

* 10. Name of Facilitator(s):

Question Title

* 11. Were any of the following standardized elements included in the scenario?Check all that apply.

Question Title

* 12. Were there any safety concerns identified in the simulation?

Question Title

* 13. Simulator used? (see ankle bracelet for color and age of manikin)Check all that apply.

Question Title

* 14. Task trainer used? Check all that apply.

Question Title

* 15. Equipment used? Check all that apply.

Question Title

* 16. Were there any issues with mannequins or other equipment?*Please also identify on exit checklist in the lab*

* 8. Length of session (in hours)
ie. a session that took place from 09:00-11:30 would be 2.5

* 11. Were any of the following standardized elements included in the scenario?
Check all that apply.

* 13. Simulator used? (see ankle bracelet for color and age of manikin)
Check all that apply.

* 14. Task trainer used?
Check all that apply.

* 15. Equipment used?
Check all that apply.

* 16. Were there any issues with mannequins or other equipment?
Please also identify on exit checklist in the lab