Thanks guys for the thoughtful responses. So in commercial aviation, you have extensive simulator training initially, and then there is recurrent training at least once a year.

One thing medicine is missing is the equivalent of the "SOP manual". If people are coming to these sessions without a review of correct responses to time critical situations, then the chance of success on the simulator is much less than if procedures were regularly reviewed.

Another thing we are missing is the FAA. There is a myriad of people writing regulations for healthcare including medical boards, specialty societies, and patient safety organizations. Regulations are often written by nonphysicians, and some entities have been found to be riddled with conflicts of interest to the point where even a state medical board was stripped of much of its authority.

To give you an idea of the scope of the safety issue in medicine, the estimate of yearly U.S. mortality from medical errors is from 44k to 98K deaths per year and if hospital aquired infections are included, the number approaches 200k. Regretably, after ~12 years of a national mobilization to attack this problem, we cannot show significant overall improvement in the last 12 years. However, we have found isolated areas where rapid improvement has occurred. In each case, some evidence based practice, or a "bundle" of practices was fully adopted by a health care entity.

Thus, if simulation has value, (and I believe it does) then it should produce a measurable effect if it is correctly implemented, and it is fully adopted. So it seems we have two problems in this area:
1. Poor implementation. No SOP manual and infrequent use. I would expect the benefit would fade over time. One session every 10 years seems far too little.
2. Incomplete implementation. Current requirements effect only a small percentage of practitioners (guessing at 10% or less).

I hope this doesn't sound like a rant. I am hoping to explain why there has been little measurable improvement in medical safety, and give some specific ideas about what we must do differently.