KEY POINTS

1. Simulators and the use of simulation have become an integral part of medical education, training, and research during the last 10 years. The pace of developments and applications is very high and the results are promising.
2. Different types of simulators can be distinguished: computer- or screen-based microsimulators and mannequin-based simulators. The latter can be divided into script-based and model-based simulators.
3. The development of mobile and less expensive simulator models allows for substantial expansion of simulator training to areas where this training could not be applied or afforded thus far. However, the biggest expenses for good simulations are not the simulator hardware, but the personnel costs.
4. Realistic simulations are an ideal method to demonstrate mechanisms of error development and train their countermeasures. The ACRM course model with its ACRM key points is the de facto world standard for anesthesia simulator training.
5. Simulator training is being adapted by many other fields outside anesthesia (emergency medicine, neonatal care, intensive care, medical and nursing school). Teaching goal-centered simulations should prevail over mere "adventurous experience of critical incidents."
6. Simulators have proved to be very valuable in research to study human behavior and failure modes under conditions of critical incidents, as well as in the development of new treatment concepts (telemedicine) and in support of the biomedical industry (e.g., device beta-testing).
7. Simulators have been extensively used as research tools for studying methods of performance assessment, although this use is still controversial.
8. Assessment of nontechnical skills (or behavioral markers) has evolved to a hallmark of judging medical excellence inside and outside simulators. A new system has been introduced to anesthesia (ANTS).
9. The most important part of simulator training is the self-reflective video-assisted debriefing session after the scenarios. The debriefing is most strongly influenced by the quality of the instructor, not the fidelity of the simulator.
10. Simulators are just the tools for an effective simulation learning experience. Therefore, the education and training of instructors (train the trainer) are of utmost importance.