At most hospitals, mock code programs have a narrow focus: the resuscitation response following cardiac arrest. Brigham and Women’s Hospital has a more ambitious vision for its mock codes.

The Brigham’s program is a collaborative effort overseen by the Department of Quality and Safety, the Emergency Response Committee, and the Neil and Elise Wallace STRATUS Center for Medical Simulation. In partnership with local unit leadership, the program plans and conducts high-fidelity in situ simulations throughout the hospital at least once a month. These events not only allow participants to practice critical resuscitations but also test the resiliency of hospital systems for emergency response.

“At many hospitals, there are quality and safety initiatives and there are simulation education initiatives. However, they don’t necessarily line up in a coherent fashion, and the simulations may only take place a couple of times a year,” says Paul S. Jansson, MD, MS, an emergency and critical care medicine physician and lead for quality and safety programs at the STRATUS Center.

“Being intentional about integrating quality and searching for opportunities to improve the system is what differentiates us from most other hospitals, where mock codes are just about practicing CPR,” adds Andrew J. Eyre, MD, MS, an emergency medicine physician and medical director for STRATUS.

Testing Emergency Response Systems Through Simulation

The Brigham’s mock code program is about two decades old. Upon its inception, a key goal was to bring simulation equipment from STRATUS (which had recently been launched) into the hospital so that more users could gain valuable simulation experience.

From the outset, an even more crucial goal has been to expand the use of simulation beyond education to test emergency response systems. This has meant exploring questions like:

• Do the emergency announcements in the hospital work appropriately?
• Do people know the number for the emergency response line?
• Can people find the emergency equipment promptly?
• Can security lead the code team to the appropriate place, and do the right personnel show up?

“Compared to programs that are about the education and the medical thinking, this has been much more about the logistics and the systems of the hospital,” Dr. Eyre says. “We’ve been running the program for a long time. It’s become part of the culture.”

Since taking over leadership of the program in early 2024, Dr. Jansson has changed the mindset. Previously, he says, the approach to mock codes was reactive. Participants would perform CPR on a manikin and afterward discuss what they could have done better. The locations of the events were often selected without much strategic thought.

The program is now more deliberative and proactive in its planning. Dr. Jansson and Quality and Safety review hospital reports to identify quality and safety concerns, which are then reflected in the simulations. As a result, the code team often ends up in locations far outside of patient rooms.

“It’s not uncommon for us to respond to a real-life medical emergency in an unexpected area,” Dr. Jansson says. “So instead of just putting the manikin in a hospital bed, we’ll place it in a lobby, stairwell, or public restroom.”

Aiming for Realism in Simulations

The program strives to create a clinical environment that is as authentic as possible, starting with using the hospital system to activate the institution-wide code protocol. Upon their arrival on the scene, the members of the hospital-wide code team encounter a manikin that can receive an IV and be defibrillated and intubated. They can open up the code chart and administer the medications inside before transporting the manikin to the appropriate unit.

After the event, program representatives review photos and other documentation with the code team and discuss areas for improvement. Maintaining a positive atmosphere in these sessions is essential, Dr. Jansson says.

“We tell people that we’re not here to shame, blame, or criticize you,” he says. “We’re here to support you, and we want your input about how to make the system better. If you make a mistake or something isn’t 100% perfect, that’s okay. In fact, it’s a benefit for us because it helps us problem solve and ensure we get things right the next time a real patient is involved.”

Besides creating a culture of psychological safety, Drs. Jansson and Eyre stress the importance of building institutional support for a vigorous mock code program. At the Brigham, enhanced communications have been key to achieving this goal.

“In the past, this was more of a secretive process—only the people in the program knew when a mock code was going to happen,” Dr. Eyre says. “We’re much more intentional about involving nursing leadership, for example, in these decisions, and that’s helped with buy-in. Plus, the relevant people are there to witness or partake in it and then give their advice on how to do it better.”