Patient safety in ambulance services - a scoping review

Notes

Permissions

Chapter 1 Background

The clinical role of the ambulance service has changed dramatically over the last few decades. The 1980s saw the widespread introduction of paramedics and the possibility of delivering life-saving interventions, the 1990s saw more sophisticated equipment and the development of national clinical guidelines, with treatments expanding to cover many diseases in addition to immediately life-threatening conditions, and, in the 2000s, work progressed on ambulance services undertaking definitive care, discharging patients either after telephone advice alone or after face-to-face contact. Over this time, more specialist roles have developed, requiring advanced skills for specific individuals. This has all been accompanied by a continuing increase in the number of 999 calls and individual incidents. All these factors increase the potential risks of adverse events (AEs) in ambulance care as more complex treatments and procedures are undertaken.

The costs of AEs in the health-care setting are considerable at both the personal and institutional levels. Most information on, and research in, patient safety is based on hospital data, with some in primary care, but little is known about patient safety in ambulance services in which the environment, the personnel and the conditions seen can mean that AEs may differ. A retrospective review of medical records in two UK hospitals estimated that 1 in 10 patients experiences an AE,1 with 50% of such events potentially having been preventable had lessons been learnt from previous incidents. 2 Despite the increasing body of evidence informing on the occurrence of AEs within hospitals, corresponding data informing on patient safety when using ambulance services are lacking.

The publication of two seminal reports To Err is Human: Building a Safer Health System3 and An Organisation with a Memory4 more than 10 years ago highlighted an urgent need to systematically study and understand the extent and nature of harm that patients are exposed to in health-care settings. These reports led to the initiation of studies to quantify the incidence of harm, predominantly in hospital-based care and qualitative research to identify the failure mechanisms that result in patient harm. The research showed that underlying attitudes and assumptions concerning safety within health-care settings are a serious obstacle to implementing sustainable improvements. The ability to quantify the safety culture (i.e. safety-related attitudes, staff values and beliefs) of an organisation, and then go on to develop a systems-oriented safety culture, became a major aim. The growing focus on safety interventions has led to the publication of an increasing body of literature that describes interventions and attempts to quantify patient benefit. There is obviously a risk when introducing these interventions into ambulance services without first making a diagnosis of the safety issues.

Patient safety has moved up the agenda for the hospital setting; however, there is little documented evidence as to how ambulance services identify issues or assess the impact of AEs. As < 50% of ambulance services and none of the associated professional bodies signed up to the Patient Safety First campaign,2 safety could be construed to be a lower priority for NHS ambulance services than for hospital services in the NHS. Before the start of this project, a preliminary review of the published literature concerning patient safety in ambulance services showed that the evidence base for patient safety in ambulance services lags behind those for other health-care sectors; furthermore, there is no systematic evidence review to direct policy, service delivery and future research.

An additional preliminary review of websites relating to patient safety identified few resources for ambulance services and no specific consideration of the applicability of generic interventions to this setting. National Patient Safety Agency (NPSA) data identified a wide variation in AE reporting between ambulance services and showed that fewer incidents were reported than by other health-care sectors. Potential reasons for this remain unclear, but it is generally accepted that low AE rates are usually owing to poor reporting rather than because incidents are not occurring. A recent PhD thesis5 suggested that prioritisation of work to improve clinical quality in line with national performance targets may take attention away from patient safety; alternatively, the safety culture in ambulance services may not be conducive to disclosure of AEs. There is clearly a need for further work to explore how ambulance services respond to patient safety issues and to understand how to optimise their engagement with safety initiatives.

There is a growing focus on patient safety across all health-care sectors and, although litigation in ambulance services is infrequent,6 rates are increasing. There is, therefore, an urgent need for robust evidence synthesis to characterise the evidence base associated with AE reporting in NHS ambulance services. This scoping review will help to highlight gaps in understanding and to direct future research and, as such, this project represents a starting point for prioritising and improving ambulance service safety processes in order to make patient care safer.

Chapter 2 Research questions and objectives

The aim of this scoping review was to identify and synthesise the available evidence relating to patient safety when using ambulance services and to identify gaps in the evidence base concerning UK ambulance services and their international equivalents. It should be noted that this review will highlight research concerning patient safety when using ambulance services and identify which questions and topics remain unanswered. Therefore, specific clinical, process or organisational questions, such as the safety of endotracheal intubation in the pre-hospital environment, cannot be definitively answered by this review, as they will need to be the subject of specifically designed reviews. It should also be noted that the search strategy (see Table 1) was designed to find studies concerning patient safety in ambulance services; therefore, not all studies on a particular topic will be found, only those that specifically explore patient safety or use the term ‘safety’ or its variants in the paper are identified.

Three research questions were defined for the project:

1. What is the national and international evidence base for patient safety in ambulance services?

2. What are the significant gaps in the evidence base for which research might add value, through either addressing new questions or replicating international research in the NHS setting?

3. What are the priorities for future policy and research?

The objectives were:

1. To undertake a scoping systematic literature review and seek opinion and advice from ambulance experts to identify the current body of evidence related to patient safety, and identify gaps in the evidence base in UK ambulance services and their international equivalents.

2. To review and analyse documents/reports/data to determine patient safety processes in English ambulance services.

3. To synthesise the evidence to identify significant gaps in the evidence base and recommend research that might add value, through addressing new research questions, replicating inadequately powered studies or replicating international research in the NHS setting.

4. To undertake a prioritisation exercise with key stakeholders in ambulance service patient safety to consider the findings of the evidence synthesis, in order to gain consensus for future policy and research.

5. To disseminate the findings of this scoping exercise, evidence synthesis and prioritisation exercise on patient safety in ambulance services and relevant related emergency services, setting out the recommendations for best use of the available evidence to direct policy and practice, highlighting gaps in the evidence base and indicating prioritised future research needs.

Chapter 3 Scoping systematic literature review

Methods

Study design

A scoping systematic review of the literature was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, when appropriate (see Appendices 1 and 2). 9

No restrictions were placed on study design and both prospective and retrospective data were included; no language restrictions were applied.

Literature reports were included in the scoping systematic review if they considered any patient (child or adult) receiving health care from ambulance services or transferred to further care by ambulance services. Reports were eligible if they considered any setting (pre-hospital, primary or secondary care) in which patients received health care, in part or in full, from ambulance services.

Primary outcomes considered in the analysis of patient safety reporting comprised avoidable harm, risk of harm, morbidity and mortality arising from medical error, AEs, litigation cases or other patient safety incidents.

Search strategy for eligible studies

The search strategy used for this scoping systematic review is detailed in Table 1. It was developed in MEDLINE and searches of other databases were adapted from this template.

TABLE 1 - Scoping systematic review search strategy for MEDLINE (12 October 2011)

EMS, emergency medical services.

All other search strategies can be found in Appendix 3.

#	Searches
1	Safety
2	Exp Safety/
3	Safety management
4	Exp Safety management/
5	Safety indicator$
6	Patient safety
7	1 OR 2 OR 3 OR 4 OR 5 OR 6
8	Pre-hospital OR pre hospital OR pre-hospital
9	Ambulance$
10	Transportation of patient$
11	Emergency medical service$OR EMS
12	Paramedic$
13	Emergency care assistant$
14	Emergency medical technician$
15	Advanced practitioner$
16	Community first responder$
17	Exp Transportation of Patients/
18	Exp Ambulances/
19	Exp Emergency Medical Technicians/
20	Exp Allied Health Personnel/
21	Exp Emergency Medical Services/
22	8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21
23	7 AND 22
24	Limit 18 to yr=“1980-current”

In discussion with the steering group, further medical subject headings (MeSH) and key terms relevant to patient safety and the ambulance services were collated. Using different combinations, 27 search strategies were developed and tested against a set of key papers related to patient safety. The search strategy selected achieved high sensitivity and moderate specificity and performed better than a validated search filter. 10

Data sources

Databases were searched from 1 January 1980 to 12 October 2011 and included MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts (ASSIA), Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium, NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database and Health Technology Assessment, the FADE Library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE). Zetoc (The British Library’s Electronic Table of Contents) was used for the main journals in the field/conference proceedings. Reference lists from key papers and citations identified as being potentially relevant were also searched.

A Google search of websites was conducted using the advanced search option, which initially considered the first 20 pages of results. In addition, the NHS Confederation website was searched.

It is argued that searching electronic databases alone will find only approximately half of the relevant literature on pre-hospital topics;11 therefore, experts were consulted to ensure that any new data were included in the scoping systematic review process.

Screening

The titles and abstracts of all retrieved citations were screened by six reviewers for their relevance to the topic of patient safety when using ambulance services. Disagreements concerning relevance were resolved by discussion with an additional reviewer who had not been involved in the initial screening. The full text was retrieved for all citations considered potentially relevant.

Literature selection

Literature selection criteria were kept broad, in line with the aims and intentions of a scoping review. The decision to use broad criteria was based on discussion with experts in emergency medicine and patient safety; input from the project advisory group (see Acknowledgements) was also sought.

Inclusion criteria

Citations were included in the scoping systematic review if they contained original data concerning any patient for whom ambulance services had been contacted and the outcome was avoidable harm/risk of harm by acts of omission or commission.

Exclusion criteria

Citations were excluded if they:

• were off topic, for example road traffic collisions

• considered the wrong setting

• considered the wrong population, for example related to the safety of staff rather than patients

• did not provide research methods, for example overviews, opinion, letters, comments, etc.

• contained research that was reported elsewhere

• had a study that was in progress or planned, but with no preliminary findings reported

• were not specific to ambulance services-general care/guidance

• did not have an available English abstract

• had research that had been superseded

• reported from a disaster or military context

• were a retracted paper.

The full table of excluded studies can be found in Appendix 4 or at www.warwick.ac.uk/ambulancesafety and the reason for exclusion with the number excluded in each category can be found in Appendix 5.

Data extraction

The search identified 24,255 studies, of which 330 were identified as relevant and included in the review (Figure 1). Although the search identified a large number of citations that addressed the topic under consideration, many gave opinions and comments on patient safety and were excluded as they did not contain assessable data. The majority of the studies were observational, including cohort studies, case–control studies, case reports and surveys. Some studies reported randomised controlled trials (RCTs) and there were some systematic reviews.

FIGURE 1.

Study identification (PRISMA) revised.

Information on study design, year and country of publication, environment, participants, interventions and outcomes was extracted using the predefined data extraction form.

Planned analysis

This scoping systematic review will identify citations that specifically explore patient safety or use the term ‘safety’ or its variants. As a scoping systematic review, it is not possible to answer specific clinical, process or organisational questions such as ‘what is the safety and effectiveness of paramedic endotracheal intubation?’, as such questions would require a subject-specific systematic review; therefore, it is not appropriate to combine data for a meta-analysis and a narrative analysis will be presented.

The data were mapped against the patient safety frameworks listed below, in a card-sorting task with the steering group. The frameworks are designed to account for factors contributing to patient safety incidents. Each framework focuses on different aspects of patient safety, as they explore different perspectives, including systems approaches and incident types:

1. Agency for Healthcare Research and Quality (AHRQ) conceptual framework

2. London Protocol

3. National Reporting and Learning Service framework

4. Patient Safety First Safety Domains

5. Yorkshire Contributory Factors framework.

The mapping exercise demonstrated that no one single framework could adequately account for the breadth of evidence retrieved from the scoping systematic review. Therefore, the card-sorting exercise was repeated to develop a new framework that could account for the data, and the resulting topic grid comprised 25 topic areas (Figure 2).

FIGURE 2.

Literature topic areas.

Chapter 4 Document review and analysis

In response to changes in out-of-hours cover and the national pressure to reduce hospital admissions, the scope of ambulance service activity has changed dramatically in both volume and breadth over the last 10 years. The principles of ‘see and treat’ (ambulance staff assessing and completing relevant treatment without onward transport) have evolved so that ambulance services increasingly take responsibility for an entire patient health-care episode. As a result, there is an increasing need for a strong patient safety culture in ambulance services that should include positive leadership and an environment that promotes quality and patient safety.

This chapter seeks to identify the prominence of patient safety activity reported in publicly available documents produced by ambulance services. The first element of the review concentrates on the views of ambulance services and perceptions of patient safety. The second element examines issues identified by agencies such as the NPSA, the NHS Litigation Authority (NHSLA) and coroners’ reports under rule 43.

Annual reports and quality accounts

Introduction

Annual reports

NHS foundation trusts are required by law (NHS Act 2006)393 to produce an annual report. Such reports are laid before parliament each year and then published to the wider community. Reports follow a defined structure394 that specifies a directors’ report including a management commentary, a remuneration report, the disclosures set out in the NHS foundation trust code of governance, a quality report, staff survey, regulatory ratings, other disclosures in the public interest, a statement of the accounting officer’s responsibilities and an annual governance statement.

NHS organisations can highlight information such as:

• patient care activities

• descriptions of how an NHS trust uses its foundation trust status to develop services and improve patient care (note that at the time of this research, no ambulance trusts had achieved foundation trust status)

• performance against key health-care targets

• procedures for monitoring health-care improvements and progress towards national and local targets

• information concerning Care Quality Commission (CQC) assessments

• the response of the NHS foundation trust to recommendations, progress towards targets, key quality improvements, new or revised services, service improvements, improvements in patient/carer information and information on complaint handling.

Quality accounts

Quality accounts are annual reports generated to describe service quality to the public. 395 The primary purpose of quality accounts is to ‘encourage boards and leaders of healthcare organisations to assess quality across all healthcare services they offer. They allow leaders, clinicians, governors and staff to demonstrate their commitment to continuous, evidence-based quality improvement, and to explain their progress to the public.’ [© Crown copyright 2010, Contains public sector information licensed under the Open Government Licence v2.0 (URL: www.nationalarchives.gov.uk/doc/open-government-licence/version/2/)]. 395 The first statutory quality accounts were published in 2011, covering activity for 2009/10.

The content of quality accounts is less stringently regulated than that of annual reports. Although some parts of a quality account are mandatory, most content can be determined locally. Mandatory elements are:

1. review of ambulance services

2. decisions on areas of improvement (at least three priorities) that the service commits to for the next year and is required to report on at the end of that year

3. national and local audits

4. clinical research

5. Commissioning for Quality and Innovation goals

6. a CQC statement

7. data accuracy.

Aim

The aim of this study was to identify, characterise and compare patient safety issues, activities and priorities in English ambulance services by analysing annual reports and quality accounts.

Methods

A document review of ambulance trust annual reports and quality accounts was conducted. Annual reports for the period 2010/11 and quality accounts for the period 2010/11 were retrieved for all English ambulance trusts from their respective websites.

Annual reports

Annual reports were read in their entirety by one researcher. Subsequently, two annual reports were coded using descriptive coding. The researcher applied codes to describe the topic of data items that had a relevance to patient safety using the definition of patient safety and the inclusion criteria predefined for the systematic review. Unrelated data were discarded. The coding for these two annual reports was reviewed by a second researcher during meetings. Disagreements were resolved in discussion. The remaining annual reports were then coded by one researcher independently (these can be viewed in Appendix 6 or at www.warwick.ac.uk/ambulancesafety). Main categories of topic areas were identified in a project meeting through clustering of the codes.

Quality accounts

Quality accounts were read in their entirety by one researcher. Data items that described trust priority areas for 2010/11 relating to aspects of patient safety were coded using descriptive codes. Owing to the structured nature of quality accounts, no review by a second researcher was deemed necessary. Main categories of trust priorities relating to patient safety were identified in a project meeting through clustering of codes.

Results

Annual reports

Annual reports for all English ambulance services (n = 11) were identified and reviewed. All reports followed the prescribed structure in terms of director and finance reporting; they ranged in length from 35 to 173 pages with considerable variation, for example in style and the number of illustrations.

Searching the annual reports for the free-text term ‘patient safety’ produced a range of hits (Figure 3); one service did not mention ‘patient safety’, whereas three ambulance services dedicated a whole chapter to the topic. The absence of the identifying phrase ‘patient safety’ does not necessarily mean that an annual report failed to discuss safety concerns or activities; the ambulance service (service 2) that did not use the phrase provided considerable data concerning improved turnaround times that had been identified as a system issue with a detrimental effect on patient care; the use of control centres providing senior-level clinical advice to address hear and treat/referral demands; and public engagement to collect feedback and patient experiences while promoting an open and fair culture. Furthermore, ambulance service 2 mentioned ‘patient safety’ eight times in its quality account for the same year. As such, the search for the term ‘patient safety’ was not a rigorous identifier of such activities.

FIGURE 3.

Number of times ‘patient safety’ was mentioned in annual reports and quality accounts by 11 English ambulance services.

The detailed review of the text of each report identified the following categories of topic areas:

1. reported patient safety issues: cleanliness and infection control, safeguarding, response time targets, other (including patient falls, handover delay, dementia and pain management)

2. improved care: NHS and alternative pathways, patient record forms, see/hear and treat/refer, other (including medicine management, computer-aided dispatch, new equipment and training and skill enhancement)

3. incident reporting and complaints

4. CQC compliance status

5. NHSLA level

6. recognition of new clinical indicators

7. public involvement: patient experience, end-of-life care

8. patient safety activities: campaigns, research, other (patient questionnaires)

9. safety culture including non-punitive reporting systems and being open

10. internal control

11. foundation trust status.

These categories of safety topics included methods of performance measures (numbers 4–6 and 11 above) and issues/activities concerning patient safety (numbers 1–3 and 7–10 above). Topic areas in both types of categories show that annual reports tended to focus on service performance and compliance with national standards.

Quality accounts

The consistent structure used for quality accounts enabled analyses to focus on safety priorities identified by ambulance services for 2010/11. Five of 11 English ambulance services did not group priorities under the areas of patient safety, clinical effectiveness and patient experience while the other six did; only two ambulance services clearly stated whether their 2010/11 priorities had been met.

Review of the areas prioritised by 11 English ambulance services in 2010/11 identified activities grouped under the six categories (Figure 4). Infection prevention and control was prioritised by seven ambulance services; safeguarding was prioritised by four ambulance services; patient safety incidents and culture were prioritised by four ambulance services; use and development of care pathways was prioritised by four ambulance services; the improvement of operational effectiveness was prioritised by five ambulance services; and public involvement and response to public needs was prioritised by four ambulance services.

FIGURE 4.

Categories of trust priorities and number of ambulance services prioritising these categories in 2010/11.

Operational effectiveness and public engagement are usually associated with patient experience rather than patient safety; only two such activities were clearly stated as patient safety priorities.

Activities to promote or prioritise patient safety that were reported by ambulance services in annual reports and quality accounts comprised:

Infection prevention and control

1. review and standardisation of cleaning products

2. training and audit

3. appointment of an infection control nurse specialist/lead for infection prevention and control/hygiene assistants

4. infection prevention and control notice boards

5. job descriptions obliging new staff to comply with infection prevention and control policies and procedures

6. improved availability of hand-washing materials

7. provision of spill kits and sanitary wipes

8. issuing regular letters to staff to remind them of the importance of training

9. roll-out of the ‘cleaner care’ initiative.

Safeguarding

1. partnership work with other trusts

2. job descriptions obliging staff to make safeguarding a priority

3. education and awareness

4. advice and information provision on the staff intranet

5. revision of a referral system

6. communication with relevant agencies across the region

7. increasing the number of safeguarding referrals

8. introduction of a single point of access to which crews refer.

Patient safety incidents and culture

1. improved reporting of patient safety incidents

2. development of patient safety strategy through four work streams

3. education and awareness

4. use of the SBAR technique as a structured communication tool

5. introduction of patient safety visits

6. commissioning of programmes with the NHS institute for innovation and improvement

7. cultural and safety surveys of staff

8. monitoring of medication errors to ensure mitigation before trends develop

9. introduction of a ‘managing medicines’ group

10. employment of ambulance pharmaceutical advisor

11. referral of patient experiences to the board.

Care pathways and clinical decision-making

1. introduction of new care pathways for stroke, heart attack and major trauma

2. facilitating continuous accessibility to stroke thrombolysis

3. public engagement

4. partnerships across different NHS bodies

5. introduction of pre-hospital therapeutic hypothermia

6. reinforcement of the ‘see and treat’ procedure.

Operational effectiveness

1. optimising patient handover by increasing the rate of patient care record submission, posting patient care record submission audit findings on the staff intranet, reintroduction of security wallets and use of an archiving company

2. improving availability of vehicles and equipment for staff

3. new care triage system for NHS pathways

4. identification of frequent callers and supporting nursing homes to prevent unnecessary calls

5. increasing the number of registered paramedics

6. electronically linking the patient care record to the initial emergency call to ensure completeness of health-care records and improved care quality

7. use of electronic patient care records

8. initiation of a learning academy for new call takers and protocol review for existing call handlers.

Public involvement/identifying patient needs

1. partnership with other health-care providers to reduce the number of calls and admissions

2. establishment of systems for entering end-of-life management plans into call centres

3. education of staff in regional hospices

4. development of a clinical dashboard to inform the public about care quality

5. recruitment of an end-of-life project lead

6. development of rapid transfer procedures to enable end-of-life patients to die in a setting of their choice

7. development of the ‘chain of survival’ partnership

8. recruitment of additional community-first responders, staff responders and introduction of public-access defibrillators.

We mapped the themes identified in the literature review to the themes that were identified in the review of ambulance performance documents, Figure 5. There were matches between fifteen (green boxes on Figure 5) domains out of the 25 domains identified during the literature review. Reporting in the ambulance documents universally followed a fairly standard pattern of (1) description of problem, (2) description of proposed/implemented solution and (3) effect of solution. Although there was modest agreement between the topics identified through the literature search, we found no references that the patient safety literature had been consulted in scoping the solutions to the patient safety issues identified.

FIGURE 5.

Mapping domains identified in the literature review and review of ambulance service documents.

Discussion

Exploring the published annual reports and quality accounts of ambulance services provided evidence that issues related to patient safety were frequently reported in these documents. There was a lack of concise or consistent terminology used when describing patient safety issues. This meant that at times it was difficult to clearly identify issues as patient safety as opposed to delivery of clinical care. It was noted that most reporting occurred in relation to reporting performance against external targets such as EMS response time, infection prevention and control, etc. Although this provides some reassurance that performance targets are identifying issues about patient safety, the apparent lack of a systematic approach from a patient safety perspective in most services raises uncertainty about the comprehensiveness or thoroughness by which patient safety issues are addressed. It further suggests that performance measurement drives safety initiatives and that a culture of meeting targets is deeply engrained. For example, infection prevention and control was the area that more than half of ambulance services prioritised in 2010/11. Activities in this area focused on staffing, training and raising staff awareness; however, no reports of infection due to uncleanliness were described to explain why these activities were initiated.

Activities grouped under care pathways included the prioritisation of alternative pathways for stroke and trauma patients in order to reduce hospital admission, reflecting a response to national priorities. Patient safety activities also reflected the uptake of ideas relating to the Patient Safety First campaign, although only five ambulance services signed up. The review did identify examples of best practice and these are highlighted particularly in category 2 above (see Results, Annual reports) and included attempts to improve reporting of patient safety incidents through staff engagement. The SBAR was adopted by one service to improve communication, particularly around handover.

There was a degree of commonality between the categories identified in these reports and the high-level themes identified during the literature review (15 out of 25 matches). We found no evidence that the contemporary literature had been consulted by ambulance services in scoping solutions to the problems identified. However, as reported in Chapter 3, the bulk of the literature focused on assessment, management and treatment, which may explain the lack of drawing on published evidence to scope solutions to patient safety problems.

This review aimed to understand ambulance service perceptions concerning patient safety but is based on what the ambulance services report in official documents, the format and subheadings of which are centrally prescribed. It is therefore possible that patient safety activities may not be fully reflected in the content of these reports. From these reports, the extent to which ambulance services prioritise patient safety cannot be determined and the question remains whether or not the way ambulance services think about safety and the way in which it is reported should be addressed.

Conclusions

There is little consistency regarding the information on attitudes and approaches to patient safety as presented in the official reports produced by ambulance services. The apparent lack of a common language and terminology makes it difficult to determine the extent to which patient safety is being addressed within ambulance services. This hinders the ability to draw conclusions whether or not the safety issues perceived as priorities for ambulance services meet the patient safety needs identified by organisations such as the NPSA, NHSLA and by coroners’ reports.

National Patient Safety Agency patient incident report data

Introduction

In 2000, the Department of Health published four requirements to be met by the NHS to facilitate learning from AEs, comprising:

1. unified mechanisms for AE reporting and analysis

2. a more open culture in which errors or service failures can be reported and discussed

3. mechanisms to ensure that when lessons are identified, the necessary changes are put into practice

4. a wider appreciation of the value of the system approach to preventing, analysing and learning from errors. 1

The NPSA was established in 2001 to identify patient safety issues nationally, collate confidential incident reports and find appropriate solutions to the causal event, and provide feedback to enable organisations to improve patient safety. 2 The resulting patient safety incident report data are published on a 6-monthly basis for every health-care trust. They present statistics on reported patient safety incident types according to NPSA categories, publish a comparison of the statistics for individual organisations and assess reports of incidents and near misses by looking at the frequency of reporting and degree of harm. Trusts receiving the reports are encouraged to act on them to improve patient safety. The first NPSA Patient Safety Incident Report data were published in March 2009. 396

Aim

The aim of this study was to review NPSA incident report data for English ambulance services to consider the occurrence of patient safety incidents and the main incident types.

Methods

Incident report data for English ambulance services were accessed and downloaded from the Organisation Patient Safety Incident Reports on the NPSA website397 for the reporting periods from:

1. April 2010 to September 2010

2. October 2010 to March 2011

3. April 2011 to September 2011.

Data for the individual ambulance services were collated in a single database and displayed comparatively using descriptive statistics and a summary of trends was reported. It was initially hoped that some secondary analysis of data might be possible. Unfortunately, because of the reorganisation of the NPSA, it was not possible to obtain this level of data in the required timescale.

Results

Figure 6 shows AEs reported by the 10 English ambulance services during the 6-month assessment periods from April 2010 to September 2011. Ambulance services are presented in order of decreasing size (resident population served in 2010/11). When considering the data for April to September 2011, there is a trend for ambulance services serving greater numbers of people to report more incidents. For four ambulance services (East of England, West Midlands, London and North East) AE reporting increased from April 2010 to September 2011 and, in contrast, the numbers of AEs reported decreased for the North West, Yorkshire and South Western. In London and the North East the number of events reported increased dramatically by three and eight times, respectively, for April to September 2011 as compared with the previous 6-month period. For the other trust areas the number of AEs reported fluctuated over the assessment period.

FIGURE 6.

Incidents reported to the NPSA by ambulance trusts in 2010–11. a, Ambulance services that joined the Patient Safety First campaign.

The percentage of reported incidents per 999 call is highly variable between ambulance services, with a range from 0.042 to 0.165 (Table 9). It is recognised that the variation in reporting rates has two main influences: a low rate may be caused by a failure to report incidents within the organisation, which may be related to organisational culture; however, a low rate may, more rarely, also be due to few incidents. In most scenarios, it is generally accepted that a high rate of reporting of low-level incidents is a positive sign and indicates a culture open to learning from such reports. Without more detailed analysis, including looking at the ratio of severe to minor incidents reported, no further judgement can be made on the significance of this variation.

TABLE 9 - Percentage of incidents reported to NPSA per 999 calls, by ambulance trust (April 2010 to September 2011)

Ambulance services that joined the Patient Safety First campaign.

Ambulance trust	Number of incidents reported to NPSA	Number of 999 calls	% incidents per 999 call
East Midlands	531	893,067	0.059
East of Englanda	625	1,040,073	0.060
Great Western	166	394,251	0.042
London	935	1,587,198	0.059
North East	253	542,226	0.047
North West	1152	1,351,995	0.085
South Centrala	261	585,111	0.045
South East Coasta	242	871,551	0.028
South Westerna	986	596,870	0.165
West Midlandsa	706	1,095,653	0.064
Yorkshire	832	923,840	0.090

Delays in reporting AEs to the NPSA are summarised in Figure 7. In the reporting period from April 2011 to September 2011 the mean time to reporting incidents to the NPSA was 36 days.

FIGURE 7.

The time delay in reporting incidents to the NPSA by English ambulance services in 2010–11 (the line indicates the mean reporting delay of 36 days).

Figure 8 shows the proportion of incidents reported by ambulance services in comparison with other care environments and suggests that ambulance services may be less likely to report than other hospital settings. However, it is possible that differences may relate to the sizes of the different care settings and the duration of care (ambulance services care for patients for a very short period of time compared with other NHS organisations).

FIGURE 8.

Proportion of AEs reported to the NPSA by different care settings for a 3-month reporting period between April 2010 and March 2011. This figure is based on dates that incidents were reported to have occurred. Data from National Reporting and Learning System, NHS England, reproduced with permission. URL: www.nrls.npsa.nhs.uk/resources/healthcare-setting/ambulance-service/. Contains public sector information licensed under the Open Government Licence v2.0, www.nationalarchives.gov.uk/doc/open-government-licence/version/2/.

Reporting of AEs to the NPSA by ambulance services classified by incident type is presented in Figure 9; the data suggest that ambulance services most frequently report patient safety issues concerning access, admission, transfer and discharge, and patient accidents (any incident resulting in avoidable harm). Self-harming behaviour and infection control were reported at lower frequencies.

FIGURE 9.

The proportions of incidents reported to the NPSA by ambulance services by incident type (April 2010–March 2011). Contains public sector information licensed under the Open Government Licence v2.0 (URL: www.nationalarchives.gov.uk/doc/open-government-licence/version/2/).

Discussion

The NPSA has developed a system to collate and review confidential patient safety incident reports on a national basis from all care settings. The data are publicly available and a rich source of summary data on AE reporting. This evaluation found that relative to other health-care sectors (e.g. acute hospital trusts, community services and mental health services) ambulance services report small numbers of incidents annually. There is variation in the frequency with which ambulance services reported incidents. This did not seem to be related to the size of ambulance service and may reflect different thresholds for reporting. Consequently, analysis of data reported to the NPSA is likely to miss a number of unreported incidents.

There was consistency over time in the themes that prompted reports. Access, admission, transfer, discharge (including missing patients) were reported most frequently and patient accidents were the next most common incidents; however, the absence of accident reduction activity in the quality accounts and annual reports suggests that ambulance service activity regarding patient safety is not focused on those events that occur most frequently. Therefore, published literature examining incident reports probably also lacks a focus on events that occur with a high degree of frequency.

These categories map to 9 of the 25 topic areas highlighted in the literature review (assessment/management, communication, decision-making, dispatch, equipment, medication, non-conveyance, transfers, and treatment/procedure). This analysis was limited by restricting it to the publicly available material that has been analysed by the NPSA. The reason for this was the abolishment of the NPSA in April 2012, which meant that we were unable to receive the data as we needed them. Overall, the analysis of the National Reporting and Learning System (NRLS) data may help to understand the present safety issues. However, any analysis will be limited because of the classification system of reported incidents, which is designed for secondary care and not ambulance services.

NHS litigation authority data

Introduction

There is an increasing trend towards litigation in health services both nationally6 and internationally. Litigation incurs costs for the NHS health-care budget and finances used would be better spent on patient care. 6 The causes of litigation are varied and include communication errors,103 road traffic collisions,398 negligence, treatment delays,399 and inadequate assessment and/or treatment. It is important to understand the nature of incidents to enable lessons to be learnt by ambulance services.

Aims

The aims of the study were to assess the pattern of litigation claims against ambulance services in England; to consider whether or not the number of cases increases over time; what the causes, outcomes, and costs of litigation are; and what lessons can be learnt.

Methods

This study retrospectively reviewed claims reported to the NHSLA by ambulance service trusts in England over the period 1995/96 to 2010/11. Reports were assessed if they related to the pre-hospital care (including health-care settings allied to pre-hospital care) and litigation arising from emergency and transport services. Incidents could involve adults or children receiving pre-hospital care. As the data set was anonymised, details of the claimant’s age, sex and presenting condition were not provided; sex was sometimes indicated, but was not systematically reported. The anonymised data were collated and analysed using IBM Statistical Product and Service Solutions (SPSS) version 19.0 software (IBM Corporation, Armonk, NY, USA) and the data set comprised 733 cases. One case was input as a negative value and, as the NHSLA was unable to provide an explanation, the case was excluded from analyses.

The main outcome measure assessed was the number of claims that resulted from mistakes and/or poor service and the cost of such claims.

Results

Open compared with closed cases

Of the assessed cases, 20.6% (151/732) were open, 78.6% (575/732) closed and 0.8% (6/732) were classified as ‘incident’ at the time of this study; the definition for incident cases could not be clarified. For all six incident cases, no damages were awarded but all other data points for the claimants were available. Therefore, for the purposes of these analyses, incident cases were treated as open.

Specialties involved

Although the primary specialty involved in the litigation incident was pre-hospital care, 15 other specialties were also involved including accident and emergency (A&E), primary care, mental health services and obstetrics, and dual-specialty involvement accounted for 14.2% of cases (104/732).

Trends in litigation

The number of litigation claims increased over the time period from 1995/6 to 2005/6 and thereafter numbers plateaued. In 1995/6, there were three claims compared with 77 in 2005/6 (Figure 10). Data for 2010/11 were incomplete at the time of this study.

FIGURE 10.

The number of litigation claims per annum from 1995/6 to 2010/11 (n = 733).

Litigation causes

Litigation resulted from a wide variety of causes, and in 8.2% (60/732) of cases was due to multiple factors. The primary cause of incidents is presented in Table 10. Of the 32 categories identified, the most common causes of litigation were lack of assistance (26.1%, 191/732), failed or delayed treatment (18.4%, 135/732), failed or delayed admission to hospital (12.0%, 88/732) and failed or delayed diagnosis (10.8%, 79/732).

TABLE 10 - Cause of the incident (n = 732)

Cause of incident	% (n/all incidents)
Lack of assistance/care	26.1% (191/732)
Failed/delayed treatment	18.4% (135/732)
Failed/delayed admission to hospital	12.0% (88/732)
Failed/delayed diagnosis	10.8% (79/732)
Failed/delayed referral to hospital	6.4% (47/732)
Inappropriate treatment	4.5% (33/732)
Failure to recognise a complication	3.1% (23/732)
Failure to supervise	3.1% (23/732)
Inadequate nursing care	2.6% (19/732)
Equipment malfunction	1.6% (12/732)
Operator error	1.5% (11/732)
Lack of facilities/equipment	1.4% (10/732)
Other/unknown/not specified	2.5% (18/732)
Error with agent/dose/route, etc.	0.8% (6/732)
Application of excess force	0.7% (5/732)
Wrong diagnosis	0.5% (4/732)
Assault, etc., by hospital staff	0.4% (3/732)
Failure to act on abnormal test results	0.4% (3/732)
Incorrect injection site	0.4% (3/732)
Slip or trip	0.4% (3/732)
Failure to warn/informed consent	0.3% (2/732)
Fell into/from an object	0.3% (2/732)
Infusion problems	0.3% (2/732)
Medical errors	0.3% (2/732)
Defective tools/equipment	0.1% (1/732)
Inappropriate discharge	0.1% (1/732)
Injuries to others by patient	0.1% (1/732)
Intraoperative problems	0.1% (1/732)
Intubation problems	0.1% (1/732)
Manual handling	0.1% (1/732)
Self-harm	0.1% (1/732)
Failure to carry out observations	0.1% (1/732)

The outcome of litigation incidents

A total of 47 outcomes were reported for litigation incidents and 10.1% (74/732) of cases had multiple outcomes. In 25.7% (188/732) of cases, the incident led to death of the patient. Other serious outcomes are described in Table 11. In some cases, the incident outcome had serious and permanent consequences for both the patient and their family in terms of lifestyle and well-being: in 5.5% (40/732) of cases the patient suffered brain damage; other life-limiting conditions included paraplegia (1.5%; 11/732), amputation (1.2%; 9/732), cerebral palsy (1.1%; 8/732), tetraplegia/quadriplegia (1.1%; 8/732), stroke (0.8%; 6/732), partial paralysis (0.3%; 2/732) and incontinence (0.1%; 1/732).

TABLE 11 - Outcomes resulting from the incident (n = 732)

Outcome of incident	% (n/all incidents)
Fatality	25.7% (188/732)
Unnecessary pain	24.0% (176/732)
Fracture	9.4% (69/732)
Brain damage	5.5% (40/732)
Psychiatric/psychological damage	3.3% (24/732)
Poor outcome: fractures, etc.	3.0% (22/732)
Bruising/extravasation	2.6% (19/732)
Spinal damage	2.6% (19/732)
Cardiac arrest	2.3% (17/732)
Additional/unnecessary operation(s)	1.6% (12/732)
Paraplegia	1.5% (11/732)
Amputation (lower)	1.2% (9/732)
Joint damage	1.2% (9/732)
Tissue damage	1.2% (9/732)
Cerebral palsy	1.1% (8/732)
Nerve damage	1.1% (8/732)
Tetraplegia/quadriplegia	1.1% (8/732)
Loss of baby	0.8% (6/732)
Other	0.8% (6/732)
Scarring	0.8% (6/732)
Stroke	0.8% (6/732)
Unknown	0.7% (5/732)
Meningitis	0.5% (4/732)
Other visual problems	0.5% (4/732)
Burn(s)	0.4% (3/732)
Cardiovascular condition	0.4% (3/732)
Dislocation	0.4% (3/732)
Multiple injuries	0.4% (3/732)
Not specified	0.4% (3/732)
Orthopaedic injuries	0.4% (3/732)
Respiratory disorder/failure	0.4% (3/732)
Bladder damage	0.3% (2/732)
Other infection	0.3% (2/732)
Partial paralysis	0.3% (2/732)
Perforation	0.3% (2/732)
Rupture	0.3% (2/732)
Stillborn	0.3% (2/732)
Anaphylactic shock/allergic shock/allergy	0.1% (1/732)
Bowel damage/dysfunction	0.1% (1/732)
Developmental delay	0.1% (1/732)
Facial injuries	0.1% (1/732)
Head injuries	0.1% (1/732)
Incontinence	0.1% (1/732)
Liver damage	0.1% (1/732)
Loss of lung	0.1% (1/732)
Lung disease	0.1% (1/732)
Multiple disabilities	0.1% (1/732)
Oedema	0.1% (1/732)
Reduced life expectancy	0.1% (1/732)
Removal of testicle	0.1% (1/732)
Tendon damage	0.1% (1/732)

Location of the incident

Litigation incidents arose at a number of different locations, but most took place in the patient’s home (42.6%; 312/732) or in the ambulance/during transfer to further care (14.8%; 108/732). The remaining locations where the incident occurred are listed in order of frequency: public place, ambulatory care/diagnostic treatment centre, clinical area, A&E, non-clinical area, unknown, call/control centre, support services, general practitioner (GP) surgery, health centre/out-of-hours centre, nursing home, day care services, outpatient department, prison/remand centre, residential care home, dental surgery, or intermediate care setting.

Costs of litigation

For most closed litigation claims (60.2%; 346/575) no damages were paid. The highest amount awarded was £2.8M, with an average cost per settlement of £10,591.57. The highest settlements (≥ £500,000) were for cases of brain damage. Costs were incurred by claimants undertaking litigation and the highest cost reported was £200,000. The average cost for claimants was £4526.88 [standard deviation (SD) £16,296.28]. Costs for defending claims were also reported, with the highest being £122,160.06 and the average cost of defence being £2482.65 (SD £8584.45).

The total cost of claims per year was highest in 2001/2 when settlements reached £3.5M, after which there was a decline with £105,997 paid in damages to 30 claimants in 2009/10 (Table 12). However, the total amount paid in 2001/2 was skewed by one large payment of £2.8M and, if this is excluded from the analyses, there was a gradual reduction in the amount paid out from 2004/5.

TABLE 12 - Costs of damages per year for closed cases (n = 575)

N/A, not applicable.

Year	Number of cases	Total cost per year (£)	Mean (£)	SD
1995/6	3	8000.00	2666.67	4618.80
1996/7	1	0	N/A	N/A
1997/8	6	85,000.00	14,166.67	34,701.10
1998/9	20	241,500.00	12,075.00	33,823.18
1999/00	35	28,875.00	825.00	2213.39
2000/1	41	69,795.25	1702.32	4600.23
2001/2	51	3,549,916.66	69,606.21	3.94
2002/3	54	966,648.87	17,900.91	70,335.40
2003/4	53	144,609.00	2728.47	5207.76
2004/5	60	1,162,000.70	19,366.68	43,847.97
2005/6	70	435,938.60	6227.69	13,352.60
2006/7	62	353,858.25	5707.39	19,665.68
2007/8	37	300,622.18	8124.92	25,280.65
2008/9	45	291,549.55	6478.8789	16,108.54
2009/10	30	105,997.00	3533.2333	6767.04
2010/11	7	8719.00	1245.57	1937.90

The gradual reduction in the amount paid to claimants is mirrored by a reduction in the cost of defending these actions since the peak in 2001/2. Details of the 15 most costly litigation claims are presented in Appendix 7.

Discussion

Although the number of litigation claims has plateaued since 2006/7 and the amount of compensation claimants receive has decreased, claims are still made against the ambulance service. The most common reasons for claims include lack of assistance or care, failed or delayed treatment, failed or delayed transfer and failed or delayed diagnosis. The exact cause of litigation incidents was generally unclear and the level of detail provided in the source data set was insufficient for detailed analysis.

Most damages were awarded when the incident resulted in a fatality but the highest levels were awarded when the incident led to brain damage, in recognition of the need for lifetime care. The decrease in the amount of damages paid over time does not appear to be owing to the ambulance service mounting a fierce defence of the action, as the cost of defending cases also fell since the peak in 2001/2.

A number of limitations seriously impact the interpretations that can be drawn from the litigation data presented here. Certain anomalies in the data set could not be explained by the NHSLA, such as the inclusion of minus values for damages and the ‘incident’ category included in the closed and open variable, and no data were provided on patient age, sex, presenting condition or the discipline and level of experience of the ambulance clinician. Incident descriptions were poor, there were no data on the ambulance services involved and it was therefore unclear whether or not some services are subject to more litigation than others. The data from the litigation agency are limited, as not all safety incidents will be reported.

There is also concern regarding the validity of the data provided by the NHSLA. In 2008, Dobbie and Cooke6 published an analysis of litigation claims from 1995 to 2005 and reported 17 cases for which the damages exceeded £1M; however, only one settlement for damages exceeded £1M in our data set for 1995 to 2011. It is difficult to explain this discrepancy, which has not been clarified by the NHSLA. As a result, definitive conclusions cannot be drawn concerning the number of litigations cases brought over time.

The top 10 causes of incidents (see Table 10) resulting in litigation have been mapped against the 25 topic areas and found to encompass eight of these: assessment/management, diagnosis, equipment/resources, individual factors, non-conveyance, observation/monitoring, skill set and treatment/procedures. However, it is recognised that the ability to detect all categories is limited by the coding system used, hence some underlying causes may be omitted.

Conclusions

This analysis provides a snapshot of patient safety incidents over a 15-year period, providing limited data on the nature, cause and costs incurred. Although the data suggest a plateau in the number of litigation claims against the ambulance service and a decrease in the cost of damages paid over recent years, limitations in incident description and data set quality preclude in-depth analysis of the cause. However, given the inadequacies in the data set it is difficult to draw definitive conclusions, one area that ambulance services should examine and aim to reduce is the number of incidences of failed or delayed treatment.

The NHSLA should consider the limitations in the quality of its data and aim to develop a more consistent, detailed and reliable reporting system.

Coroners’ reports

Introduction

Her Majesty’s Coroner is responsible for investigating sudden, unnatural or unexplained deaths as well as sudden deaths in the community and deaths for which the cause is uncertain; therefore, situations when there are concerns about the care received prior to death are referred to the coroner. The coroner (or their officer) will investigate the circumstances surrounding the death and will decide whether or not an inquest is to be held. When an inquest is held, witnesses are called (e.g. clinical staff, pathologist, relatives) to present evidence relevant to the cause of death. If inquest evidence suggests that there might be a risk of future deaths and action is needed to prevent recurrence, the coroner prepares a report under rule 43, which suggests actions to prevent future deaths. These reports can be served to all involved or with an interest in an incident and require a response by the recipients stating whether or not the suggested actions will be taken and, if they are not going to be taken, indicating the reason why.

Aim

The aim was to summarise the issues that caused the coroner to send a report to an ambulance service under rule 43 in order to identify patient safety incidents with ambulance service involvement.

Methods

Summaries of the coroners’ reports were accessed at www.justice.gov.uk/publications/policy/moj/summary-of-reports-and-responses-under-rule-43-of-the-coroners-rules. 400 The summaries of coroners’ reports issued from 2008 to 2011 were screened for ambulance service involvement and relevant documents were then downloaded for review. This period was chosen because 2008 is the time when the letters became publicly available in one location. To obtain letters before this time would have required contacting every coroner and this was not considered feasible.

A thematic analysis was undertaken to identify patient safety issues that triggered coroners’ reports. For consistency, the categories identified for use in the prioritisation exercise (see Chapter 6) were used for classification of the summaries of the coroners’ reports. The summaries were analysed with a view to identifying potential patterns in incident types and the receiving ambulance service.

The decision to issue a rule 43 letter is personal to the coroner when he or she believes that it may prevent a similar future death. The number undertaken by each coroner is highly variable. The information recorded on this database has been abstracted by a non-researcher at the Ministry of Justice and it is, therefore, their opinion of the key issues that are analysed. Although this study adds information about some cases, it cannot be considered a representative sample of coroners’ cases when safety issues were present.

Results

The search identified 25 reports sent to ambulance services between July 2008 and March 2011. Of these, 22 involved nine English ambulance services. Figure 11 illustrates the number of reports sent to each ambulance service, taking into account the number of people served. Given the small number issued, the findings suggest an even spread of coroners’ reports across the majority of English ambulance services.

FIGURE 11.

Number of coroners’ reports received by English ambulance services between July 2008 and March 2011.

Table 13 details the actions required by rule 43 notices. The patient safety issues that triggered more than half of coroners’ reports related to communication issues and patient assessment skills. Communication was the main focus of seven notices and, of these, four related to communication between the ambulance service and hospitals, two related to internal communication issues and one related to interagency (police) communication. Assessment was relevant to eight notices (four relating to assessment/treatment of specific conditions, three to clinical assessment skills and one to record keeping). Other notices were grouped under the headings of training (one), treatment (four), organisation/culture (three) and equipment (two).

TABLE 13 - Summary of actions issued to English ambulance services under rule 43, by category

Category	Rule 43 ruling
Communication	Hospital and ambulance service to consider improving communication between health professionals
	To consider the relationship between the ambulance service and hospital staff and the process of transmitting ambulance records to A&E staff to enable continuity of care
	Ambulance service to consider a review of transmission of ambulance records to hospital staff to enable continuity of care
	To consider sending notification of road closures by e-mail rather than post, or consider if such information could be integrated with central control/ambulance navigation systems
	To consider disseminating guidance to all ambulance trusts about best practice for communications between call centres and ambulance crews
	To consider a review of the police airwave system and communication between police and ambulance services when ambulance personnel attend the scene of a violent incident
	To consider a review of policy to enable the communication of important patient medical information to the ambulance area responding to the request
Assessment	Ambulance service to include a pain score on their record sheet
	Ambulance service to consider reminding technicians to conduct their own medical assessments
	Ambulance service to consider a review of guidelines for assessment of patients who appear drunk
	Ambulance service to consider a review of guidance when an ambulance is called to a police station
	To consider provision of ambulances to people advised to contact the emergency services if their condition deteriorates after discharge from hospital following major surgery
	To consider incorporating other sources of information at initial diagnosis, particularly the ambulance service’s patient report form; reviewing procedures for assessment of fitness for discharge and reviewing policy on initiating serious untoward incident procedures
	To consider issuing guidance to operators to ask callers what drugs the patient has taken (if any)
	To consider a review of how information provided to the ambulance service and NHS Direct is assessed and to ensure that a diagnosis of metabolic ketoacidosis is considered when symptoms could indicate this condition
Training	To consider a review of training on excited delirium and risk assessment both at the scene of arrest and the police station; the use of police vehicles to transport prisoners to hospital; guidance on monitoring and observing prisoners; guidance for forensic medical examiners at the police station; guidance on calls to the ambulance service and how they should be handled
Treatment	To consider a review of protocols and guidance on prescribing antibiotics in A&E when a patient displays possible symptoms of meningitis; to consider guidance to ambulance staff on keeping possible items of evidence and accurate recording of observations
	To consider providing adrenaline, amiodarone and atropine to ambulance services in different coloured boxes to avoid confusion
	To continue efforts to provide places of safety for people with mental health concerns
	To consider allowing patients to use walking aids with which they are familiar, including when travelling by ambulance
Organisation/culture	To consider evidence from the inquest in carrying out the critical incident review
	Ambulance service to consider a review of its policy on solo responders attending emergencies and crew meal break arrangements
	To consider disseminating the action plan arising from their serious untoward incident investigation to all ambulance services throughout England
Equipment	To consider providing equipping ambulance crews with equipment to effect forcible entry and training in its use
	To consider rigorous servicing of all defibrillator equipment in accordance with service schedules; decommissioning and replacing all defibrillator batteries and improving ambulance staff training in the use of defibrillators

Discussion

This study of coroners’ rule 43 reports identified 25 notices that were issued over a 3-year period (2008–11). The main reason for serving a rule 43 coroners’ report to ambulance services involved communication issues. Ambulance services often represent the first point of contact for a patient with acute, potentially life-threatening events. Communication plays a key role in ensuring effective dispatch (from the control centre to the scene), liaison with relevant agencies (e.g. police, carers) at the scene and ensuring that information obtained at the first contact is recorded and communicated effectively to hospital staff (in the event the patient is transferred to hospital) or those responsible for follow-up care (e.g. social services, GPs). Successful communication requires a systems approach to ensure that information is passed effectively within and between organisations. The seven rule 43 notices identified by this study provide examples of where communication may have failed and contributed to the death of a patient. Ensuring that ambulance services have effective communication systems in place is an important priority.

The second key theme of the coroners’ reports related to weaknesses in patient assessment and identified areas such as deficiencies in record keeping, and assessment and management of specific clinical conditions. Some, but not all, issues arose in the context of patients assessed on scene and when a decision was made to leave the patient at the scene rather than transfer them to hospital for further assessment and treatment. Such a see-and-treat approach has the potential to be resource effective, but requires careful evaluation to ensure that patient outcomes are improved rather than a delay being experienced in provision of necessary care; ensuring that the see-and-treat approach retains a focus on patient outcome is key to the provision of safe and effective care. The inclusion of recontact rates in national quality indicators represents a useful starting point for this process.

It is recognised that the information from this study may not be representative, as it covers only cases for which a coroner issues a rule 43 notice. The decision to do this is at the personal discretion of each coroner.

The review of rule 43 notices was useful in highlighting examples of lapses in patient care pathways that resulted in death. However, shortcomings in this evidence must be acknowledged: 25 reports is a small number and is an insufficient basis for development of firm conclusions; the reports are associated with individual patient cases and generalisation of the results is not necessarily appropriate; summary reports provide little information that is suitable for analysis or to facilitate identification of underlying safety issues; and, finally, the number of reports received by an ambulance service should not be used to reflect the quality of services offered, as the number of reports also relates to the number of people served and the coroner’s perception of the incident.

All the rulings were mapped to three topic areas of the 25 highlighted in the literature review, namely assessment/management, communication and non-conveyance.

Chapter 5 Staff and user perception in ambulance services

Chapter 6 Prioritisation exercise

Chapter 7 Discussion

This scoping exercise has used a multimethods approach, consulting a wide range of patients and professionals, and has highlighted the paucity of good evidence to support patient safety initiatives relating to ambulance services. The existing data sources do not enable ambulance services to study the causation of AEs or to understand the clinical risks. Equally, there is a lack of evidence concerning the effectiveness of specific interventions.

Overarching themes of the combined results

The matrix of 25 topic areas developed in the literature review has been used to illustrate the issues detected by the various components and demonstrate the recurring themes. This is illustrated in Figure 12.

FIGURE 12.

Mapping domains identified by different components of the scoping review. Topics are colour coded by frequency of detection by different components of this scoping review. Dark green, detected by six components; light blue, detected by five components; dark blue, detected by four components; light green, detected by three components; mid green, detected by two components; mid blue, detected by one component. A, annual reports; C, coroners; D, Delphi; L, literature; M, medical directors; N, NHS LA; O, NPSA; P, public engagement.

Four areas were highlighted by five of the eight studies:

1. assessment/management

2. communication

3. equipment/resources

4. non-conveyance.

These are all topics with a large amount of literature to inform initial decision-making, although, as highlighted in the scoping review, the quality is poor. Other topics in order of the number of methods that detected them as an issue are shown in Figure 12.

Throughout this work, two major cross-cutting themes also emerged:

1. The information was not recorded in a consistent manner in various databases, nor in their descriptions in the literature. This lack of definition and consistency of use makes information difficult to interpret and implement change based on the data. Therefore, we recommend that this is addressed in future work.

2. The information from organisations and individuals revealed that there was little systematic use of the literature or databases. This may be cultural, or may be because of the difficulty of obtaining or utilising the information. We hope this report will aid this, but also encourage more evidence-based decision-making in patient safety in ambulance services.

Chapter 8 Conclusions

Acknowledgements

We would like to thank all the participants involved in this research: the ambulance service staff interviewees and participants in the prioritisation workshop and the Delphi exercise. We are particularly grateful to Geoff Aitchison, the patient representative who assisted with the development of the grant application and in the initial planning of the project.

References

1. Vincent C. Adverse events in hospitals. BMJ 2001;322:517-19. http://dx.doi.org/10.1136/bmj.322.7285.517.
2. Carruthers I, Philip P. Safety First: A Report for Patients, Clinicians and Healthcare Managers. London: The Central Office of Information; 2006.
3. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
4. An Organisation With a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS. London: The Stationery Office; 2000.
5. Wankhade P. Performance Management and Cultures in Health Care: Case Study Evidence from the NHS Ambulance Service in the United Kingdom. Liverpool: University of Liverpool; 2009.
6. Dobbie AE, Cooke MW. A descriptive review and discussion of litigation claims against ambulance services. Emerg Med J 2008;25:455-8. http://dx.doi.org/10.1136/emj.2007.052324.
7. Colwell CB, Pons P, Blanchet JH, Mangino C. Claims against a paramedic ambulance service: a ten-year experience. J Emerg Med 1999;17:999-1002. http://dx.doi.org/10.1016/S0736-4679(99)00131-6.
8. Cooke MW. CSI – Patient Safety in Ambulance Services n.d. www.warwick.ac.uk/ambulancesafety (accessed August 2014).
9. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies that Evaluate Health Care Interventions: Explanation and Elaboration. PLOS Med 2009;6. http://dx.doi.org/10.1371/journal.pmed.1000100.
10. Tanon AA, Champagne F, Contandriopoulos AP, Pomey MP, Vadeboncoeur A, Nguyen H. Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL. Qual Saf Health Care 2010;9:452-61. http://dx.doi.org/10.1136/qshc.2008.031401.
11. Wilson S, Cooke M, Morrell R, Bridge P, Allan T. A systematic review of the evidence supporting the use of priority dispatch of emergency ambulances. Prehosp Emerg Care 2002;6:42-9. http://dx.doi.org/10.1080/10903120290938760.
12. Aufderheide TP, Keelan MH, Hendley GE, Robinson NA, Hastings TE, Lewin RF. Milwaukee prehospital chest pain project – phase I: feasibility and accuracy of prehospital thrombolytic candidate selection. Am J Cardiol 1992;69:991-6. http://dx.doi.org/10.1016/0002-9149(92)90852-P.
13. Bruns BM, Dieckmann R, Shagoury C, Dingerson A, Swartzell C. Safety of pre-hospital therapy with morphine sulfate. Am J Emerg Med 1992;10:53-7. http://dx.doi.org/10.1016/0735-6757(92)90127-J.
14. Firanescu C, Wilbers R, Meeder JG. Safety and feasibility of prehospital thrombolysis in combination with active rescue PCI strategy for acute ST-elevation myocardial infarction. Neth Heart J 2005;13:300-4.
15. Flabouris A, Runciman WB, Levings B. Incidents during out-of-hospital patient transportation. Anaesth Intensive Care 2006;34:228-36.
16. Gratton MC, Ellison SR, Hunt J, Ma OJ. Prospective determination of medical necessity for ambulance transport by paramedics. Prehosp Emerg Care 2003;7:466-9. http://dx.doi.org/10.1080/31270300220X.
17. Goebel PJ, Daya MR, Gunnels MD. Accuracy of arrhythmia recognition in paramedic treatment of paroxysmal supraventricular tachycardia: a ten-year review. Prehosp Emerg Care 2004;8:166-70.
18. Lavis M, McCarthy S, Jenkins NH. The continuing need to formalize pre-hospital triage, highlighted by a case of unusual injury. J Accid Emerg Med 1995;12:206-7. http://dx.doi.org/10.1136/emj.12.3.206.
19. Lefrancois DP, Dufour DG. Use of the esophageal tracheal combitube by basic emergency medical technicians. Resuscitation 2002;52:77-83. http://dx.doi.org/10.1016/S0300-9572(01)00441-5.
20. Linn S, Knoller N, Giligan CG, Dreifus U. The sky is a limit: errors in prehospital diagnosis by flight physicians. Am J Emerg Med 1997;15:316-20. http://dx.doi.org/10.1016/S0735-6757(97)90025-5.
21. Mason S, Knowles E, Freeman J, Snooks H. Safety of paramedics with extended skills. Acad Emerg Med 2008;15:607-12. http://dx.doi.org/10.1111/j.1553-2712.2008.00156.x.
22. Matera P. Working under the wrong assumption. JEMS 2002;27.
23. Martin JE, Mehta R, Aarabi B, Ecklund JE, Martin AH, Ling GS. Intracranial insertion of a nasopharyngeal airway in a patient with craniofacial trauma. Mil Med 2004;169:496-7.
24. Rottman SJ, Schriger DL, Charlop G, Salas JH, Lee S. On-line medical control versus protocol-based prehospital care. Ann Emerg Med 1997;30:62-8. http://dx.doi.org/10.1016/S0196-0644(97)70113-6.
25. Bledsoe B. Uncover hidden trauma. JEMS 2003;28.
26. Anonymous . Punishment with a point. JEMS 2001;26.
27. Halter M, Vernon S, Snooks H, Porter A, Close J, Moore F, et al. Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study. Emerg Med J 2011;28:44-50. http://dx.doi.org/10.1136/emj.2009.079566.
28. Winslow JA, Goodman C, McMahon B. Unnecessary prehospital spinal immobilization. Ann Emerg Med 2005;46. http://dx.doi.org/10.1016/j.annemergmed.2005.06.229.
29. Brown LH, Hubble MW, Cone DC, Millin MG, Schwartz B, Patterson PD. Paramedic determinations of medical necessity: a meta-analysis. Prehosp Emerg Care 2009;13:516-27. http://dx.doi.org/10.1080/10903120903144809.
30. Jones AP, Allison K, Wright H, Porter K. Use of prehospital dressings in soft tissue trauma: is there any conformity or plan?. Emerg Med J 2009;26:532-4. http://dx.doi.org/10.1136/emj.2008.058255.
31. Knapp BJ, Tsuchitani SN, Sheele JM, Prince J, Powers J. Prospective evaluation of an emergency medical services-administered alternative transport protocol. Prehosp Emerg Care 2009;13:432-6. http://dx.doi.org/10.1080/10903120902935256.
32. Dante S, Herken U, Hammer T, Kurz M. Description of the acceleration forces affecting balance of pre-hospital providers while delivering cardio-pulmonary resuscitation. Circulation 2009;120.
33. Mirarchi FL, Kalantzis S, Hunter D, McCracken E, Kisiel T. TRIAD II: do living wills have an impact on pre-hospital lifesaving care?. J Emerg Med 2009;36:105-15. http://dx.doi.org/10.1016/j.jemermed.2008.10.003.
34. Stephenson LS. How Can the Use of Pre-Hospital Procedural Checklists Impact Patient Care in a Traditional Paramedic Culture?. Victoria, BC: Royal Roads University; 2007.
35. Weiss S, Peterson K, Cheney P, Froman P, Ernst A, Campbell M. The use of chemical restraints reduces agitation in patients transported by emergency medical services. J Emerg Med 2012;43:820-8. http://dx.doi.org/10.1016/j.jemermed.2011.02.019.
36. Hussmann B, Lefering R, Waydhas C, Ruchholtz S, Wafaisade A, Kauther MD, et al. Prehospital intubation of the moderately injured patient: a cause of morbidity? A matched-pairs analysis of 1,200 patients from the DGU Trauma Registry. Crit Care 2011;15. http://dx.doi.org/10.1186/cc10442.
37. Stohler SA, Schwartz RJ, Kent Sargent R, Jacobs LM. Quality assurance in the Connecticut helicopter emergency medical service. J Air Med Transp 1991;10:7-11.
38. Askitopoulou H, Vourvahakis D, Panagopoulos D, Mamidakis E. HECTOR emergency scale (HES) for the evaluation of prehospital emergencies. Eur J Anaesthesiol 2000;17. http://dx.doi.org/10.1097/00003643-200000002-00568.
39. Fitzpatrick D, Duncan EAS. Improving post-hypoglycaemic patient safety in the prehospital environment: a systematic review. Emerg Med J 2009;26:472-8. http://dx.doi.org/10.1136/emj.2008.062240.
40. Dale J, Williams S, Foster T, Higgins J, Snooks H, Crouch R. Safety of telephone consultation for ‘non-serious’ emergency ambulance service patients. Qual Saf Health Care 2004;13:363-73. http://dx.doi.org/10.1136/qshc.2003.008003.
41. Keeling P, Hughes D, Price L, Shaw S, Barton A. Safety and feasibility of prehospital thrombolysis carried out by paramedics. BMJ 2003;327:27-8. http://dx.doi.org/10.1136/bmj.327.7405.27.
42. Stella J, Bartley B, Jennings P. Introduction of a prehospital critical incident monitoring system – final results. Prehosp Disaster Med 2010;25:515-20.
43. Vilke GM, Marcotte A, Metz M, Ray L. Pain management in the out-of-hospital setting. Ann Emerg Med 2004;44. http://dx.doi.org/10.1016/j.annemergmed.2004.07.207.
44. Slattery DE, Heck J. An opportunity for reform: a comprehensive evaluation of non-transport patterns in an urban emergency medical services setting. Ann Emerg Med 2004;44. http://dx.doi.org/10.1016/j.annemergmed.2004.07.341.
45. Newgard CD, Hui S, Griffin A, Lewis RJ. Prospective validation of an out-of-hospital decision rule to identify severely injured children involved in motor vehicle crashes. Ann Emerg Med 2004;44. http://dx.doi.org/10.1016/j.annemergmed.2004.07.210.
46. Jensen JL, Croskerry P, Travers AH. Consensus on paramedic clinical decisions during high-acuity emergency calls: results of a Canadian Delphi study. CJEM 2011;13:310-18.
47. Michael GE, Sporer KA, Youngblood GM. Socioeconomic and clinical factors associated with prehospital analgesia. Ann Emerg Med 2006;48.
48. Nicholl J, Hughes S, Dixon S, Turner J, Yates D. The costs and benefits of paramedic skills in pre-hospital trauma care. Health Technol Assess 1998;2.
49. Coleman P, O’Hara R, Mason S, O’Keeffe C. The quality and safety of emergency care practitioner care. Emerg Med J 2009;26. http://dx.doi.org/10.1136/emj.2009.075416g.
50. Dixon M, Carmody N, O’Donnell C. The effectiveness of supraglottic airway devices in prehospital basic life support airway management. Emerg Med J 2009;26. http://dx.doi.org/10.1136/emj.2009.075416d.
51. Davies A, Mylonas MJ, Ferguson A-L, Hutton A. Case: failure of ambulance crew to treat patient: R (1&amp;2) and M(3) v Welsh Ambulance Service NHS Trust. Clin Risk 2009;15:207-9. http://dx.doi.org/10.1258/cr.2009.090064.
52. Redd JM, Bair AE. Implications of ambulance diversion. Ann Emerg Med 2003;42:S1-109.
53. Sagawa K, Inooka H, Inooka E. Mental State of Cardiac Patients During Ambulance Transportation n.d.
54. Franklin GA, Boaz PW, Spain DA, Lukan JK, Carrillo EH, Richardson JD. Prehospital hypotension as a valid indicator of trauma team activation. J Trauma 2000;8:1034-7. http://dx.doi.org/10.1097/00005373-200006000-00006.
55. Grmec S, Schaubach T, Stok E, Ferk J. Comparison of Mainz Emergency Evaluation System (MEES) and Revised Trauma Score (RTS) for prediction of mortality of trauma patients. Prehosp Disaster Med 2002;17.
56. Tindall RD. Saving Lives in Real-Time: A Pre-Hospital Telementoring Case n.d.
57. Lord B, Parsell B. Use of visual analogue scale for measurement of pain in the prehospital setting. Prehosp Disaster Med 2002;17.
58. Isaak S. Is prehospital GCS alone adequate to determine need for a trauma center?. Ann Emerg Med 2006;48.
59. Schmidt MJ, Handel D, Lindsell CJ, Collett L, Gallo P, Locasto D. Evaluating an emergency medical services-initiated nontransport system. Prehosp Emerg Care 2006;10:390-3. http://dx.doi.org/10.1080/10903120600725918.
60. Barton ED, Swanson ER, Hutton KC. Laryngoscopic visualization grade predicts difficult intubations by air medical crews in the out-of-hospital setting. Ann Emerg Med 2004;44.
61. Schmidt T, Atcheson R, Federiuk C, Mann NC, Pinney T, Fuller D, et al. Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport. Acad Emerg Med 2000;7:663-9. http://dx.doi.org/10.1111/j.1553-2712.2000.tb02041.x.
62. Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ 2007;335. http://dx.doi.org/10.1136/bmj.39343.649097.55.
63. Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced Medical Priority Dispatch System affect cardiac arrest detection?. Emerg Med J 2004;21:115-18. http://dx.doi.org/10.1136/emj.2003.006940.
64. Turner J, Lattimer V, Snooks H. An Evaluation of the Accuracy and Safety of NHS Pathways. London: Department of Health; 2008.
65. Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R. Dispatcher recognition of stroke using the national academy medical priority dispatch system. Stroke 2009;40:2027-30. http://dx.doi.org/10.1161/STROKEAHA.108.545574.
66. Hinchey P, Myers B, Zalkin J, Lewis R, Garner D. Low acuity EMS dispatch criteria can reliably identify patients without high-acuity illness or injury. Prehosp Emerg Care 2007;11:42-8. http://dx.doi.org/10.1080/10903120601021366.
67. Clawson J, Olola C, Heward A, Patterson B, Scott G. Ability of the medical priority dispatch system protocol to predict the acuity of ‘unknown problem’ dispatch response levels. Prehosp Emerg Care 2008;12:290-6. http://dx.doi.org/10.1080/10903120802100787.
68. Porteous GH, Corry MD, Smith WS. Emergency medical services dispatcher identification of stroke and transient ischemic attack. Prehosp Emerg Care 1999;3:211-16. http://dx.doi.org/10.1080/10903129908958939.
69. Deakin CD, Alasaad M, King P, Thompson F. Is ambulance telephone triage using advanced medical priority dispatch protocols able to identify patients with acute stroke correctly?. Emerg Med J 2009;26:442-5. http://dx.doi.org/10.1136/emj.2008.059733.
70. Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B. Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score. Acad Emerg Med 2006;13:954-60. http://dx.doi.org/10.1111/j.1553-2712.2006.tb00341.x.
71. Frendl DM, Strauss DG, Underhill BK, Goldstein LB. Lack of impact of paramedic training and use of the Cincinnati prehospital stroke scale on stroke patient identification and on-scene time. Stroke 2009;40:754-6. http://dx.doi.org/10.1161/STROKEAHA.108.531285.
72. Lerner EB. Studies Evaluating Current Field Triage: 1966–2005. Prehosp Emerg Care 2006;10:303-6. http://dx.doi.org/10.1080/10903120600723921.
73. Kost S, Arruda J. Appropriateness of ambulance transportation to a suburban pediatric emergency department. Prehosp Emerg Care 1999;3:187-90. http://dx.doi.org/10.1080/10903129908958934.
74. Gerlacher GR, Sirbaugh PE, Macias CG. Prehospital evaluation of non-transported pediatric patients by a large emergency medical services system. Pediatr Emerg Care 2001;17:421-4. http://dx.doi.org/10.1097/00006565-200112000-00005.
75. Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E. Accuracy of stroke recognition by emergency medical dispatchers and paramedics – San Diego experience. Prehosp Emerg Care 2008;12:307-13. http://dx.doi.org/10.1080/10903120802099526.
76. Flynn J, Archer F, Morgans A. Sensitivity and specificity of the medical priority dispatch system in detecting cardiac arrest emergency calls in Melbourne. Prehosp Disaster Med 2006;21:72-6.
77. Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke 1995;26:937-41. http://dx.doi.org/10.1161/01.STR.26.6.937.
78. Qazi K, Kempf JA, Christopher NC, Gerson LW. Paramedic judgment of the need for trauma team activation for pediatric patients. Acad Emerg Med 1998;5:1002-7. http://dx.doi.org/10.1111/j.1553-2712.1998.tb02780.x.
79. Gray JT, Walker A. Avoiding admissions from the ambulance service: a review of elderly patients with falls and patients with breathing difficulties seen by emergency care practitioners in South Yorkshire. Emerg Med J 2008;25:168-71. http://dx.doi.org/10.1136/emj.2007.050732.
80. Reilly MJ. Accuracy of a priority medical dispatch system in dispatching cardiac emergencies in a suburban community. Prehosp Disaster Med 2006;21:77-1.
81. Lord B, Williams B, Boyle M. Paramedic identification of ECG J Point and ST segments: a pilot study. AJP 2007;5. http://ro.ecu.edu.au/jephc/vol5/iss2/5.
82. Kahalé J, Osmond MH, Nesbitt L, Stiell IG. What are the characteristics and outcomes of nontransported pediatric patients?. Prehosp Emerg Care 2006;10:28-34. http://dx.doi.org/10.1080/10903120500373322.
83. Kelly AM, Nicholl J, Turner J. Determining the most effective level of TRISS-derived probability of survival for use as an audit filter. Emerg Med 2002;14:146-52. http://dx.doi.org/10.1046/j.1442-2026.2002.00309.x.
84. Smith W, Culley L, Plorde M, Murray JA, Hearne T, Goldberg P, et al. Emergency medical services telephone referral program: an alternative approach to nonurgent 911 calls. Prehosp Emerg Care 2001;5:174-80. http://dx.doi.org/10.1080/10903120190940092.
85. Price TG, Hooker EA, Neubauer J. Prehospital provider prediction of emergency department disposition. Prehosp Emerg Care 2005;9:322-5. http://dx.doi.org/10.1080/10903120590962012.
86. Kahveci FO, Demircan A, Keles A, Bildik F, Aygencel SG. Efficacy of triage by paramedics: a real-time comparison study. J Emerg Nurs 2012;38:344-9. http://dx.doi.org/10.1016/j.jen.2011.03.004.
87. Lammers RL, Roth BA, Utecht T. Comparison of ambulance dispatch protocols for nontraumatic abdominal pain. Ann Emerg Med 1995;26:579-89. http://dx.doi.org/10.1016/S0196-0644(95)70008-0.
88. Thakore S, McGugan EA, Morrison W. Emergency ambulance dispatch: is there a case for triage?. J R Soc Med 2002;95:126-9. http://dx.doi.org/10.1258/jrsm.95.3.126.
89. Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck?. Emerg Med J 2007;24:501-3. http://dx.doi.org/10.1136/emj.2006.041897.
90. Boyle MJ. Comparison overview of prehospital errors involving road traffic fatalities in Victoria, Australia. Prehosp Disaster Med 2009;24:254-61.
91. Donald M, Paterson B. Introduction of an electronic debrief and governance tool in prehospital care. Emerg Med J 2007;24:363-6. http://dx.doi.org/10.1136/emj.2006.043539.
92. Matthews A, Gavin C, O’Driscoll BR. Audit of pre-hospital oxygen therapy by North West Ambulance Service (NWAS) one year after publication of new JRCALC guidance for oxygen use. Thorax 2010;65. http://dx.doi.org/10.1136/thx.2010.151068.32.
93. Achieving Improvements Through Clinical Governance. London: The Stationery Office; 2003.
94. Safeguarding Children: A Review of Arrangements in the NHS for Safeguarding Children. London: Care Quality Commission; 2009.
95. Safe Management and Use of Controlled Drugs in the Ambulance and Paramedic Services in England. Department of Health; n.d.
96. Pons PT, Dinerman N, Rosen P, Dernocoeur K, Coxon K, Marlin R. The field instructor program: quality control of prehospital care, the first step. J Emerg Med 1985;2:421-7. http://dx.doi.org/10.1016/0736-4679(85)90251-3.
97. Spaite DW, Hanlon T, Criss EA, Valenzuela TD, Meislin HW, Ross J. Prehospital data entry compliance by paramedics after institution of a comprehensive EMS data collection tool. Ann Emerg Med 1990;19:1270-3. http://dx.doi.org/10.1016/S0196-0644(05)82286-3.
98. Bergrath S, Rortgen D, Skorning M, Fischermann H, Beckers SK, Mutscher C. Emergency mission documentation in simulated care: video-based error analysis. Anaesthetist 2011;60:221-9. http://dx.doi.org/10.1007/s00101-010-1790-y.
99. Cwinn MA, Forster AJ, Adam Cwinn A, Hebert G, Calder L, Stiell IG. Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. CJEM 2009;11:462-72.
100. Dalawari P, Duggan J, Vangimalla V, Paniagua M, Armbrecht ES. Patient transfer forms enhance key information between nursing homes and emergency department. Geriatr Nurs 2011;32:270-5. http://dx.doi.org/10.1016/j.gerinurse.2011.05.001.
101. Deakin CD, Evans S, King P. Evaluation of telephone-cardiopulmonary resuscitation advice for paediatric cardiac arrest. Resuscitation 2010;81:853-6. http://dx.doi.org/10.1016/j.resuscitation.2010.02.007.
102. Evans SM, Murray A, Patrick I, Fitzgerald M, Smith S, Andrianopoulos N, et al. Assessing clinical handover between paramedics and the trauma team. Injury 2010;41:460-4. http://dx.doi.org/10.1016/j.injury.2009.07.065.
103. Greenwood MJ, Heninger JR. Structured communication for patient safety in emergency medical services: a legal case report. Prehosp Emerg Care 2010;14:345-8. http://dx.doi.org/10.3109/10903121003760788.
104. Grow RW, Sztajnkrycer MD, Moore BR. Language barriers as a reported cause of prehospital care delay in Minnesota. Prehosp Emerg Care 2008;12:76-9. http://dx.doi.org/10.1080/10903120701709878.
105. Meisel ZF, Peacock N, Mechem CC. EMS to ED handoffs: a prospective observational analysis. Ann Emerg Med 2010;56:S87-8. http://dx.doi.org/10.1016/j.annemergmed.2010.06.313.
106. Murray S, Crouch R, Pope C, Lattimer V, Thompson F, Deakin C, et al. Improving the quality of ambulance crew hand-overs: a qualitive study of knowledge transfer in emergency care teams. Emerg Med J 2011;28. http://dx.doi.org/10.1136/emj.2010.108605.19.
107. Owen C, Hemmings L, Brown T. Lost in translation: maximizing handover effectiveness between paramedics and receiving staff in the emergency department. Emerg Med Australas 2009;21:102-7. http://dx.doi.org/10.1111/j.1742-6723.2009.01168.x.
108. Waldron R, Sixsmith D. Emergency physician awareness of out-of-hospital procedures and medications. Ann Emerg Med 2011;58. http://dx.doi.org/10.1016/j.annemergmed.2011.06.397.
109. Zimmer M, Wassmer R, Latasch L, Oberndörfer D, Wilken V, Ackermann H, et al. Initiation of risk management: incidence of failures in simulated emergency medical service scenarios. Resuscitation 2010;81:882-6. http://dx.doi.org/10.1016/j.resuscitation.2010.03.009.
110. Manser T, Foster S, Gisin S, Jaeckel D, Ummenhofer W. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care 2010;19:1-5.
111. Dalto J, Thomas F, Weir C. Analyzing communication errors in an air medical transport service. Air Med J 2011;30. http://dx.doi.org/10.1016/j.amj.2011.07.007.
112. Chan EW, Taylor SE, Marriott J, Barger B. An intervention to encourage ambulance paramedics to bring patients’ own medications to the ED: impact on medications brought in and prescribing errors. Emerg Med Australas 2010;22:151-8. http://dx.doi.org/10.1111/j.1742-6723.2010.01273.x.
113. Kerry AL, Lobo C, Milanes S, Curtis J, Maskell NA. Audit reviewing the impact of lung alert cards and ambulance crew education on inappropriate oxygen prescribing in patients with COPD. Thorax 2007;62:A64-149.
114. Strong C, Thompson CB. Documentation of decision-making during air transport. Air Med J 2000;19:77-82. http://dx.doi.org/10.1016/S1067-991X(00)90026-9.
115. Frakes MA, Robinson KJ, McQuay J. Evaluation of a modified sign-out on emergency department documentation of medications administered by critical care transport teams. Air Med J 2009;28:246-7.
116. Gustafsson M, Wennerholm S, Fridlund B. Worries and concerns experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident study. Intensive Crit Care Nurs 2010;26:138-45. http://dx.doi.org/10.1016/j.iccn.2010.01.002.
117. Brady W, Carr G, Ilton J, Robbins K. Emergency medical services transfer of patient information to emergency department personnel. Ann Emerg Med 2004;44. http://dx.doi.org/10.1016/j.annemergmed.2004.07.212.
118. Vilke GM, Castillo EM, Metz MA, Ray LU, Murrin PA, Lev R, et al. Community trial to decrease ambulance diversion hours: the San Diego county patient destination trial. Ann Emerg Med 2004;44:295-303. http://dx.doi.org/10.1016/j.annemergmed.2004.05.002.
119. Jenkin A, Abelson-Mitchell N, Cooper S. Patient handover: time for a change?. Accid Emerg Nurs 2007;15:141-7. http://dx.doi.org/10.1016/j.aaen.2007.04.004.
120. Meisel ZF, Mechem CC, Shofer FS, Feinberg DM, Pollack CV. Discrepancies between the prehospital and hospital record: what is the value of the trip sheet?. Ann Emerg Med 2006;48. http://dx.doi.org/10.1016/j.annemergmed.2006.07.688.
121. Poitras J. Delays to angioplasty for patients with ST-elevation myocardial infarction are reducible by ambulance diversion based on a out-of-hospital electrocardiogram. Ann Emerg Med 2008;52. http://dx.doi.org/10.1016/j.annemergmed.2008.06.187.
122. Siemsen IM, Madsen MD, Pedersen LF, Michaelsen L, Pedersen AV, Andersen HB, et al. Factors that impact on the safety of patient handovers: an interview study. Scand J Public Health 2012;40:439-48. http://dx.doi.org/10.1177/1403494812453889.
123. Atack L, Maher J. Emergency medical and health providers’ perceptions of key issues in prehospital patient safety. Prehosp Emerg Care 2010;14:95-102. http://dx.doi.org/10.3109/10903120903349887.
124. Moga C, Harstall C. Air Ambulance Transportation with Capabilities to Provide Advanced Life Support. Edmonton, Canada: Institute of Health Economics; 2008.
125. Meisel ZF, Mathew R, Wydro GC, Crawford Mechem C, Pollack CV, Katzer R. Multicenter validation of the Philadelphia EMS admission rule (PEAR) to predict hospital admission in adult patients using out-of-hospital data. Acad Emerg Med 2009;16:519-25. http://dx.doi.org/10.1111/j.1553-2712.2009.00422.x.
126. Hayes J, Moore A, Benwell G, Wong BLW. Ambulance Dispatch Complexity and Dispatcher Decision Strategies: Implications for Interface Design n.d.
127. Saini D. Information Needs of Pre-Hospital Care Providers – A Requirements Analysis n.d.
128. Holtermann K. Dispatch of 9-1-1 calls – a prospective study of criteria-based dispatch for determining the allocation of EMS resources. Prehosp Disaster Med 2002;17.
129. Dale J, Higgins J, Williams S, Foster T, Snooks H, Crouch R. Computer assisted assessment and advice for ‘non-serious’ 999 ambulance service callers: the potential impact on ambulance despatch. Emerg Med J 2003;20:178-83. http://dx.doi.org/10.1136/emj.20.2.178.
130. Snooks H, Halter M, Lees-Mlanga S, Koenig KL, Miller K. Appropriateness of intravenous cannulation by paramedics: a London study. Prehosp Emerg Care 2000;4:156-63. http://dx.doi.org/10.1080/10903120090941434.
131. Shah MN, Davis CO, Bauer C, Arnold J. Preferences for EMS transport and pediatric emergency department care. Prehosp Emerg Care 2008;12:169-75. http://dx.doi.org/10.1080/10903120801907059.
132. Snooks H, Kearsley N, Dale J, Halter M, Redhead J, Cheung W. Towards primary care for non-serious 999 callers: results of a controlled study of ‘Treat and Refer’ protocols for ambulance crews. Qual Saf Health Care 2004;13:435-43. http://dx.doi.org/10.1136/qshc.2003.007658.
133. Clawson J, Olola C, Heward A, Patterson B, Scott G. The Medical Priority Dispatch System’s ability to predict cardiac arrest outcomes and high acuity pre-hospital alerts in chest pain patients presenting to 9-9-9. Resuscitation 2008;78:298-306. http://dx.doi.org/10.1016/j.resuscitation.2008.03.229.
134. Dobson T, Jensen JL, Karim S, Travers AA. Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure. J Emerg Prim Health Care 2009;7.
135. Houston R, Pearson GA. Ambulance provision for children: a UK national survey. Emerg Med J 2010;27:631-6. http://dx.doi.org/10.1136/emj.2009.088880.
136. McDermott FT, Cooper GJ, Hogan PL, Cordner SM, Tremayne AB. Evaluation of the prehospital management road traffic fatalities in Victoria, Australia. Prehosp Disaster Med 2005;20:219-27. http://dx.doi.org/10.1017/S1049023X00002570.
137. Schaider JJ, Riccio JC, Rydman RJ, Pons PT. Paramedic diagnostic accuracy for patients complaining of chest pain or shortness of breath. Prehosp Disaster Med 1995;10:245-50.
138. Svilaas T, Dijk WA, Busman JP, Dassen WRM, de Vos R, Zijlstra F. The Groningen Ambulance Study n.d.
139. Dadkhah S, French SC, Fisch-Cook C, Cook E, Miller M, Chan S, et al. Now evaluate chest pain with 12-lead electrocardiograms and rapid markers for early recognition of myocardial infarctions in the ambulance (new ERA). Ann Emerg Med 1999;34. http://dx.doi.org/10.1016/S0196-0644(99)80262-5.
140. van ‘t Hof AWJ, van de Wetering H, Ernst N, Hollak F, de Pooter F, Suryapranata H. A Quantitative Analysis of the Benefits of Pre-Hospital Infarct Angioplasty Triage on Outcome in Patients Undergoing Primary Angioplasty for Acute Myocardial Infarction n.d.
141. Lecky F, Bryden D, Little R, Tong N, Moulton C. Emergency intubation for acutely ill and injured patients. Cochrane Database Syst Rev 2008;2. http://dx.doi.org/10.1002/14651858.CD001429.pub2.
142. Holliman CJ, Wuerz RC, Meador SA. Decrease in medical command errors with use of a ‘standing orders’ protocol system. Am J Emerg Med 1994;12:279-83. http://dx.doi.org/10.1016/0735-6757(94)90138-4.
143. Nicholl J, Coleman P, Parry G, Turner J, Dixon S. Emergency priority dispatch systems: a new era in the provision of ambulance services in the UK. Prehosp Immediate Care 1999;3:71-5.
144. Wastell D, Newman M. Information Systems Development in the Ambulance Service: A Tale of Two Cities n.d.
145. Wigman LD, van Lieshout EMM, de Ronde G, Patka P, Schipper IB. Trauma-related dispatch criteria for Helicopter Emergency Medical Services in Europe. Injury 2011;42:525-33. http://dx.doi.org/10.1016/j.injury.2010.03.015.
146. Schmidt T, Neely KW, Adams AL, Newgard CD, Wittwer L, Muhr M, et al. Is it possible to safely triage callers to EMS dispatch centers to alternative resources?. Prehosp Emerg Care 2003;7:368-74. http://dx.doi.org/10.1080/10903120390936590.
147. Brooks L, Fitzgerald G, Atkinson C. Using Actor Network Theory to Interpret the Introduction of Information Systems Within the London Ambulance Service n.d.
148. Gratton M, Garza A, Salomone JA, Shearer J. Ambulance staging for potentially dangerous scenes: another hidden component of response time. Ann Emerg Med 2008;52. http://dx.doi.org/10.1016/j.annemergmed.2008.06.194.
149. Larson JT, Dietrich AM, Abdessalam SF, Werman HA. Effective Use of the Air Ambulance for Pediatric Trauma n.d.
150. White L, Cudnik M, Werman H. Can prehospital triage criteria predict clinical outcomes for trauma patients transported by air. Air Med J 2011;30. http://dx.doi.org/10.1016/j.amj.2011.07.010.
151. Van Wijngaarden M, Kortbeek J, Lafreniere R, Cunningham R. Air Ambulance Trauma Transport: A Quality Review n.d.
152. McGrath CP, Rosen GS, Bechtel GA. Improving bedside to departure care in air transport of ST segment elevation myocardial infarction patients: a 2-year retrospective study of performance. Air Med J 2009;29:84-7. http://dx.doi.org/10.1016/j.amj.2009.11.001.
153. Anonymous . Ambulance errors lead to $10.2 million settlement. Healthc Risk Manag 2002;24:2-3.
154. Barry PW, Ralston C. Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child 1994;71:8-11. http://dx.doi.org/10.1136/adc.71.1.8.
155. Chollet C, Ricard-Hibon A, Marty J. Evaluation of a check list for devices used in prehospital emergency medicine. J Euro Urg 1999;12:139-47.
156. Levick N, Swanson J. An optimal solution for enhancing ambulance transport safety: a real-time driver performance monitoring and feedback device. Ann Emerg Med 2005;46:S112-13. http://dx.doi.org/10.1016/j.annemergmed.2005.06.415.
157. Madar RJ, Milligan DW. Neonatal transport: safety and security. Arch Dis Child 1994;71:F147-8. http://dx.doi.org/10.1136/fn.71.2.F147-a.
158. Wang HE, Weaver MD, Abo BN, Kaliappan R, Fairbanks RJ. Ambulance stretcher adverse events. Qual Saf Health Care 2009;18:213-16. http://dx.doi.org/10.1136/qshc.2007.024562.
159. Bleiler E. How safe are air ambulances?. Med Econ 1982;59.
160. Pham JC, Patel R, Millin M, Kirsch TD, Chanmugam A. The effects of ambulance diversion: a comprehensive review. Acad Emerg Med 2006;13:1220-7. http://dx.doi.org/10.1111/j.1553-2712.2006.tb01652.x.
161. Sulis C, Estanislao R, Wedel S. Completeness of cleaning critical care transport vehicles. Air Med J 2010;29.
162. Woollard M, Lighton D, Gregory P, Munro G, Jenkinson E, Hamilton L. Malleable stylet vs re-useable and disposable bougies in a model of difficult intubation: a randomised cross-over trial. Emerg Med J 2009;26. http://dx.doi.org/10.1136/emj.2009.075416l.
163. Eckstein M, Chan LS. The effect of emergency department crowding on paramedic ambulance availability. Ann Emerg Med 2004;43:100-5. http://dx.doi.org/10.1016/S0196-0644(03)00747-9.
164. Vourvahakis D, Zeaki M, Zervopoulos M, Zigoura A, Pyrros D. Laryngeal mask: experience from prehospital use at EKAB in Heraklion, Crete. Prehosp Disaster Med 2002;17.
165. Al Darrab A, Fernandes CM, Worster A, Woolfrey K, Moneta S. A city wide approach to reduce ambulance diversion: the Hamilton model. Ann Emerg Med 2005;46:40-1. http://dx.doi.org/10.1016/j.annemergmed.2005.06.154.
166. Bassene PH, d’Hollander A, Faller JP, Kara A, Braun JB. Pre-hospital tracheal intubation assisted by fibroscopy in patients with suspicion of cervical spine lesion: a pilot study. Crit Care 1998;2.
167. Høyer C, Christensen E, Eika B. Adverse Design of defibrillators: turning off the machine when trying to shock. Ann Emerg Med 2008;52:512-14. http://dx.doi.org/10.1016/j.annemergmed.2007.11.037.
168. Khaleghi M, Loh A, Vroman D, Chan TC, Vilke GM. The effects of minimizing ambulance diversion hours on emergency departments. J Emerg Med 2007;33:155-9. http://dx.doi.org/10.1016/j.jemermed.2007.02.014.
169. Steele R. Incidence of ambulance diversion in a small US community. Ann Emerg Med 2002;40.
170. Vilke GM, Castillo EM, Stepanski BM, Murrin PA, Upledger-Ray L, Metz MA, et al. San Diego County patient destination trial to decrease ambulance diversion hours: three year follow-up. Ann Emerg Med 2006;48. http://dx.doi.org/10.1016/j.annemergmed.2006.07.760.
171. Eckstein M, Jantos T, Kelly N. Air ambulance utilization of pediatric transport in an urban setting. Ann Emerg Med 1999;34. http://dx.doi.org/10.1016/S0196-0644(99)80114-0.
172. Meisel ZD, Branas C, Pines JM. Type of insurance is associated with ambulance use for transport to emergency departments in the United States. Ann Emerg Med 2009;54.
173. Ruger JP. Ambulance utilization practices: is 911-taxi a myth?. Ann Emerg Med 2002;40.
174. Lee SW. The use of ambulance services in the transfer of residents from community step-down facilities to a local emergency department. Ann Emerg Med 2002;40.
175. Goodloe JM, Crowder CJ, Arthur AO, Thomas SH. EMS stretcher ‘misadventures’ in a large, urban EMS system: a descriptive analysis of contributing factors and resultant injuries. Emerg Med Int 2012. http://dx.doi.org/10.1155/2012/745706.
176. Kupas DF, Shayhorn MA, Green P, Payton TF. Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors. Prehosp Emerg Care 2012;16:67-75. http://dx.doi.org/10.3109/10903127.2011.621046.
177. Thakore S, Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emerg Med J 2001;18:293-6. http://dx.doi.org/10.1136/emj.18.4.293.
178. Caulkins CG. On the scene. Do paramedics make an effort not to transport at the end of their shifts?. Emerg Med Serv 2001;30:83-5.
179. Cushman JT, Fairbanks RJ, O’Gara KG, Crittenden CN, Pennington EC, Wilson MA. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care 2010;14:477-84. http://dx.doi.org/10.3109/10903127.2010.497901.
180. Maggiore WA. Failure to transport: new lawsuits, old trends. EMS Insider 2011;38:2-3.
181. Patterson PD, Huang DT, Fairbanks RJ, Simeone S, Weaver M, Wang HE. Variation in emergency medical services workplace safety culture. Prehosp Emerg Car 2010;14:448-60. http://dx.doi.org/10.3109/10903127.2010.497900.
182. Thomas F, Hopkins RO, Handrahan DL, Walker J, Carpenter J. Sleep and cognitive performance of flight nurses after 12-hour evening versus 18-hour shifts. Air Med J 2006;25:216-25. http://dx.doi.org/10.1016/j.amj.2006.06.005.
183. Taylor CB, Stevenson M, Jan S, Middleton PM, Fitzharris M, Myburgh JA. A systematic review of the costs and benefits of helicopter emergency medical services. Injury 2010;41:10-2. http://dx.doi.org/10.1016/j.injury.2009.09.030.
184. Siriwardena AN, Iqbal M, Banerjee S, Spaight A, Stephenson J. An evaluation of an educational intervention to reduce inappropriate cannulation and improve cannulation technique by paramedics. Emerg Med J 2009;26:831-6. http://dx.doi.org/10.1136/emj.2008.071415.
185. York D, Dudek L, Larson R, Marshall W, Dries D. A comparison study of chest tube thoracostomy: air medical crew and in-hospital trauma service. Air Med J 1993;12:227-9. http://dx.doi.org/10.1016/S1067-991X(05)80187-7.
186. Shaban R, Creedy D, Clark M. Ambulance and anthrax – the challenge of infection control and infectious disease in paramedic emergency care. Prehosp Disaster Med 2002;17:S45-6.
187. Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care 2008;12:486-94. http://dx.doi.org/10.1080/10903120802290752.
188. Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of practicing paramedics. Prehosp Emerg Care 2000;4:253-60. http://dx.doi.org/10.1080/10903120090941290.
189. Mackay CA, Terris J, Coats TJ. Prehospital rapid sequence induction by emergency physicians: it is safe?. Emerg Med J 2001;18:20-4. http://dx.doi.org/10.1136/emj.18.1.20.
190. Rea TD, Edwards C, Murray JA, Cloyd DJ, Eisenberg MS. Epinephrine use by emergency medical technicians for presumed anaphylaxis. Prehosp Emerg Care 2004;8:405-10. http://dx.doi.org/10.1016/j.prehos.2004.05.006.
191. Alvarez-Ortiz NJ, Aranaz Andrés JM, Gea Velázquez De Castro MT, Miralles Bueno JJ. Pre-hospital adverse events: a way to go. Rev Calid Asist 2010;25:28-33. http://dx.doi.org/10.1016/j.cali.2009.07.009.
192. Seymour CW, Kahn JM, Schwab CW, Fuchs BD. Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit Care 2008;12:1-10. http://dx.doi.org/10.1186/cc6909.
193. McDermott C, Collins NC. Prehospital medication administration: a randomised study comparing intranasal and intravenous routes. Emerg Med Int 2012;2012:1-5.
194. Eastwood KJ, Boyle MJ, Williams B. Paramedics’ ability to perform drug calculations. West J Emerg Med 2009;10:240-3.
195. Anderson S, Hogskilde PD, Wetterslev J, Bredgaard M, Møller JT, Dahl JB. Appropriateness of leaving emergency medical service treated hypoglycemic patients at home: a retrospective study. Acta Anaesthesiol Scand 2002;46:464-8. http://dx.doi.org/10.1034/j.1399-6576.2002.460424.x.
196. Cain E, Ackroyd-Stolarz S, Alexiadis P, Murray D. Prehospital hypoglycemia: the safety of not transporting treated patients. Prehosp Emerg Care 2003;7:458-65. http://dx.doi.org/10.1080/312703002193.
197. Cooper SJR, Grant J. New and emerging roles in out of hospital emergency care: a review of the international literature. Int Emerg Nurs 2009;17:90-8. http://dx.doi.org/10.1016/j.ienj.2008.11.004.
198. Mechem CC, Barger J, Shofer FS, Dickinson ET. Short-term outcome of seizure patients who refuse transport after prehospital stabilization. Acad Emerg Med 2001;9:231-6. http://dx.doi.org/10.1111/j.1553-2712.2001.tb01298.x.
199. Gray JT, Wardrope J. Introduction of non-transport guidelines into an ambulance service: a retrospective review. Emerg Med J 2007;24:727-9. http://dx.doi.org/10.1136/emj.2007.048850.
200. Haines CJ, Lutes RE, Blaser M, Christopher NC. Paramedic initiated non-transport of pediatric patients. Prehosp Emerg Care 2006;10:213-19. http://dx.doi.org/10.1080/10903120500541308.
201. Hauswald M. Can paramedics safely decide which patients do not need ambulance transport or emergency department care?. Prehosp Emerg Care 2002;6:383-6. http://dx.doi.org/10.1080/10903120290937978.
202. Porter A, Snooks H, Youren A, Gaze S, Whitfield R, Rapport F, et al. ‘Should I stay or should I go?’ Deciding whether to go to hospital after a 999 call. J Health Serv Res Policy 2007;12:S1-32.
203. Silvestri S, Rothrock SG, Kennedy D, Ladde J, Bryant M, Pagane J. Can paramedics accurately identify patients who do not require emergency department care?. Prehosp Emerg Care 2002;6:387-90. http://dx.doi.org/10.1080/10903120290937987.
204. Snooks HA, Halter M, T Close JC, Cheung WY, Moore F, Roberts SE. Emergency care of older people who fall: a missed opportunity. Qual Saf Health Car 2006;15:390-2. http://dx.doi.org/10.1136/qshc.2006.018697.
205. Yaxley L, Aldridge V, Almond J, Greenwood RH, Heyburn PJ, Harradence F, et al. Ambulance personnel can successfully treat severe hypoglycaemia. Practical Diabetes 1993;10:67-8. http://dx.doi.org/10.1002/pdi.1960100210.
206. Socransky SJ, Pirrallo RG, Rubin JM. Out-of-hospital treatment of hypoglycemia: refusal of transport and patient outcome. Acad Emerg Med 1998;5:1080-5. http://dx.doi.org/10.1111/j.1553-2712.1998.tb02666.x.
207. Al-Sulaiti M, Snooks H, Porter A. Non-conveyance of 999 callers: early findings related subsequent health services callers. Emerg Med J 2009;26. http://dx.doi.org/10.1136/emj.2009.075416h.
208. Lerner EB, Billittier A, Lance DR, Janicke DM, Teuscher JA. Can paramedics safely treat and discharge hypoglycemic patients in the field?. Am J Emerg Med 2003;21:115-20. http://dx.doi.org/10.1053/ajem.2003.50014.
209. Sprehn M, Pedersen CB, Sorensen MB, Bendtson I. Emergency prehospital treatment of severe hypoglycemia in the Copenhagen Municipality. A retrospective analysis of 180 episodes. Ugeskr Laeger 1992;154:1101-4.
210. Strote J, Simons R, Eisenberg M. Emergency medical technician treatment of hypoglycemia without transport. Am J Emerg Med 2008;26:291-5. http://dx.doi.org/10.1016/j.ajem.2007.05.030.
211. Mechem CC, Kreshak AA, Barger J, Shofer FS. The short-term outcome of hypoglycemic diabetic patients who refuse ambulance transport after out-of-hospital therapy. Acad Emerg Med 1998;5:768-72. http://dx.doi.org/10.1111/j.1553-2712.1998.tb02502.x.
212. Burstein JL, Henry M, C, Alicandro J, Gentile D, Thode HC, Hollander JE. Outcome of patients who refused out-of-hospital medical assistance. Am J Emerg Med 1996;14:23-6. http://dx.doi.org/10.1016/S0735-6757(96)90007-8.
213. Zachariah BS, Bryan D, Pepe PE, Griffin M. Follow-up and outcome of patients who decline or are denied transport by EMS. Prehosp Disaster Med 1992;7:359-64.
214. Ruckoldt H, Marx G, Leuwer M, Panning B, Piepenbrock S. Pulse oximetry and capnography in intensive care transportation: combined use reduces transportation risks. Anasthesiologie 1998;33:32-6.
215. Garwe T, Cowan LD, Neas BR, Sacra JC, Albrecht RM. Directness of transport of major trauma patients to a level 1 trauma center: a propensity-adjusted survival analysis of the impact on short-term mortality. J Trauma Acute Care Surg 2011;70:1118-27. http://dx.doi.org/10.1097/TA.0b013e3181e243b8.
216. Snooks HA, Nicholl JP, Brazier JE, Lees-Mlanga S. The costs and benefits of helicopter emergency ambulance services in England and Wales. J Public Health 1996;18:67-7. http://dx.doi.org/10.1093/oxfordjournals.pubmed.a024465.
217. Wolfberg DM, Verdile VP, Flinn RD. Incorporating drugs and devices into emergency medical services systems. Prehosp Disaster Med 1995;10:189-94.
218. Heightman AJ. Patient security redefined. JEMS 2000;25.
219. O’Cathain A, Turner J, Nicholl JP. The acceptability of an emergency medical dispatch system to people who call 999 to request an ambulance. Emerg Med J 2002;19:160-3. http://dx.doi.org/10.1136/emj.19.2.160.
220. Goldhill D, Gemmell L, Lutman D, McDevitt S, Parris M, Waldmann C. AAGBI Safety Guideline: Interhospital Transfer. London: The Association of Anaesthetists of Great Britain and Ireland; 2009.
221. Thomas AN, Harvey JR, Hurst T. Standards for Capnography Guidelines (2011) 2011. www.ics.ac.uk/education/capnography_guidelines (accessed 6 September 2012).
222. Acker JE, Pancioli A, Crocco TJ, Eckstein MK, Jauch EC, Larrabee H, et al. Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association expert panel on emergency medical services systems and the stroke council. Stroke 2007;38:3097-115. http://dx.doi.org/10.1161/STROKEAHA.107.186094.
223. Turner J, Bjarkoy M. Developing new performance indicators for ambulance service category B calls. Emerg Med J 2011;28. http://dx.doi.org/10.1136/emj.2010.108605.21.
224. Lloyd MS, Heeke B, Walter PF, Langberg JJ. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 2008;117:2510-14. http://dx.doi.org/10.1161/CIRCULATIONAHA.107.763011.
225. Derr C, O’Conner B, Klash A, Galwankar S, MacLeod S. The use of continuous positive airway pressure for the treatment of acute severe pulmonary edema in the prehospital setting. Ann Emerg Med 2006;48. http://dx.doi.org/10.1016/j.annemergmed.2006.07.765.
226. McGlinch B, Weller E. Patient outcomes following prehospital rapid sequence intubation for medical emergencies. Crit Care 2004;8. http://dx.doi.org/10.1186/cc2753.
227. Fairbanks RJ, Crittenden CN, O’Gara KG, Wilson MA, Pennington EC, Chin NP, et al. Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. Acad Emerg Med 2008;15:633-40. http://dx.doi.org/10.1111/j.1553-2712.2008.00147.x.
228. Hobgood C, Bowen JB, Brice JH, Overby B, Tamayo-Sarver JH. Do EMS personnel identify, report, and disclose medical errors?. Prehosp Emerg Care 2006;10:21-7. http://dx.doi.org/10.1080/10903120500366011.
229. Price L. Treating the clock and not the patient: ambulance response times and risk. Qual Saf Health Care 2006;15:127-30. http://dx.doi.org/10.1136/qshc.2005.015651.
230. Price R, Bendall JC, Patterson JA, Middleton PM. What causes adverse events in prehospital care? A human-factors approach. Emerg Med J 2012;30:583-8. http://dx.doi.org/10.1136/emermed-2011-200971.
231. Cooper S, O’Carroll J, Jenkin A, Badger B. Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner – quantitative findings. Emerg Med J 2007;24:630-3. http://dx.doi.org/10.1136/emj.2007.048058.
232. Sukumaran S, Henry JM, Beard D, Lawrenson R, Gordon MW, O’Donnell JJ, et al. Prehospital trauma management: a national study of paramedic activities. Emerg Med J 2005;22:60-3. http://dx.doi.org/10.1136/emj.2004.016873.
233. Bahner DP. Prehospital ultrasonography training: a five-month pilot study. Ann Emerg Med 2002;40.
234. Barsuk D, Ziv A, Lin G, Blumenfeld A, Rubin O, Keidan I. Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care. Anesth Analg 2005;100:803-9. http://dx.doi.org/10.1213/01.ANE.0000143390.11746.CF.
235. Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM. Do specialist transport personnel improve hospital outcome in critically ill patients transferred to higher centers? A systematic review. J Crit Care 2006;21:8-17. http://dx.doi.org/10.1016/j.jcrc.2005.12.008.
236. Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Arntz H-R, Mochmann H-C. Expertise in prehospital endotracheal intubation by emergency medicine physicians – comparing ‘proficient performers’ and ‘experts’. Resuscitation 2012;83:434-9. http://dx.doi.org/10.1016/j.resuscitation.2011.10.011.
237. Cobas MA, De la Pena MA, Manning R, Candiotti K, Varon AJ. Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg 2009;109:489-93. http://dx.doi.org/10.1213/ane.0b013e3181aa3063.
238. Cushman JT, Hettinger AZ, Farney A, Shah MN. Effect of intensive physician oversight on a prehospital rapid-sequence intubation program. Prehosp Emerg Care 2010 n.d.;14:310-16. http://dx.doi.org/10.3109/10903121003760200.
239. Davis BD, Fowler R, Kupas DF, Roppolo LP. Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful?. Curr Opin Crit Care 2002;8:571-77. http://dx.doi.org/10.1097/00075198-200212000-00015.
240. Davis DP, Pettit K, Rom CD, Poste JC, Sise MJ, Hoyt DB, et al. The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel. Prehosp Emerg Care 2005;9:191-7. http://dx.doi.org/10.1080/10903120590924500.
241. Davis JE, Churosh N, Borloz M, Howell J. Knowledge of self-injectable epinephrine technique among emergency medical services providers. Ann Emerg Med 2009;1. http://dx.doi.org/10.1016/j.annemergmed.2009.06.139.
242. Fakhry SM, Scanlon JM, Robinson L, Askari R, Watenpaugh RL, Fata P, et al. Prehospital rapid sequence intubation for head trauma: conditions for a successful program. J Trauma Injury Inf Crit Care 2006;60:997-1001. http://dx.doi.org/10.1097/01.ta.0000217285.94057.5e.
243. Gatsoulis N, Tzafestas N, Damaskinos A. Pre-hospital trauma deaths in a tourist region in Greece. Prehosp Immediate Care 2000;4:117-21.
244. Hein C, Owen H, Plummer J. A training program for novice paramedics provides initial laryngeal mask airway insertion skill and improves skill retention at 6 months. Simul Healthc 2010;5:33-9. http://dx.doi.org/10.1097/SIH.0b013e3181b5c3fb.
245. Harris T, Lockey D. Success in physician prehospital rapid sequence intubation: what is the effect of base speciality and length of anaesthetic training?. Emerg Med J 2011;28:225-9. http://dx.doi.org/10.1136/emj.2009.088302.
246. Hein C, Owen H, Plummer J. A 12-month audit of laryngeal mask airway (LMA) use in a South Australian ambulance service. Resuscitation 2008;79:219-24. http://dx.doi.org/10.1016/j.resuscitation.2008.06.014.
247. Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ. Emergency physician-verified out-of-hospital intubation: miss rates by paramedics. Acad Emerg Med 2004;11:707-9.
248. Howerton D, Watson B. An air medical company’s review of crew duty time and the effects on endotracheal intubation success rates. Air Med J 2010;29.
249. Meyer PG, Orliaguet G, Blanot S, Jarreau MM, Charron B, Sauverzac R, et al. Complications of emergency tracheal intubation in severely head-injured children. Paediatr Anaesth 2000;10:253-60. http://dx.doi.org/10.1046/j.1460-9592.2000.00496.x.
250. Pace SA, Fuller FP. Out-of-hospital succinylcholine-assisted endotracheal intubation by paramedics. Ann Emerg Med 2000;35:568-72. http://dx.doi.org/10.1016/S0196-0644(00)70029-1.
251. Parwani V, Hoffman RJ, Russell A, Bharel C, Preblick C, Hahn IH. Practicing paramedics cannot generate or estimate safe endotracheal tube cuff pressure using standard techniques. Prehosp Emerg Care 2007;11:307-11. http://dx.doi.org/10.1080/10903120701348248.
252. Sloane C, Vilke GM, Chan TC, Hayden SR, Hoyt DB, Rosen P. Rapid sequence intubation in the field versus hospital in trauma patients. J Emerg Med 2000;19:259-64. http://dx.doi.org/10.1016/S0736-4679(00)00235-3.
253. Schmidt U, Stalp M, Gerich T, Blauth M, Maull KI, Tscherne H. Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications. J Trauma 1998;44:98-101. http://dx.doi.org/10.1097/00005373-199801000-00010.
254. Warner KJ, Copass MK, Bulger EM. Paramedic use of needle thoracostomy in the prehospital environment. Prehosp Emerg Care 2008;12:162-8. http://dx.doi.org/10.1080/10903120801907299.
255. Wang HE, Cook LJ, Chang CC, Yealy DM, Lave JR. Outcomes after out-of-hospital endotracheal intubation errors. Resuscitation 2009;80:50-5. http://dx.doi.org/10.1016/j.resuscitation.2008.08.016.
256. Wang HE, Lave JR, Sirio CA, Yealy DM. Paramedic intubation errors: isolated events or symptoms of larger problems? These emergency treatment errors could be an important indicator of out-of-hospital care quality. Health Aff 2006;25:501-9. http://dx.doi.org/10.1377/hlthaff.25.2.501.
257. Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care 2007;11:213-18. http://dx.doi.org/10.1080/10903120701205935.
258. Yeung KL, Yeung GWY, Chan MWS, Lee SB, Choi KT, Lee LL. Knowledge of inter-facility transport among emergency nurses in Hong Kong: a questionnaire survey. Int Emerg Nurs 2008;16:159-64. http://dx.doi.org/10.1016/j.ienj.2008.05.001.
259. Palazzo K, Stuhlmiller D, Funk D, Tilney P, Thomas S. Analysis of HEMS individual endotracheal intubation attempt. Air Med J 2011;30. http://dx.doi.org/10.1016/j.amj.2011.07.006.
260. Olasveengen TM, Lund-Kordahl I, Steen PA, Sunde K. Out-of hospital advanced life support with or without a physician: effects on quality of CPR and outcome. Resuscitation 2009;80:1248-52. http://dx.doi.org/10.1016/j.resuscitation.2009.07.018.
261. Kryder GD, Jang TB, Tan D. Key factors in out-of-hospital intubation suggested for further training. Ann Emerg Med 2004;44. http://dx.doi.org/10.1016/j.annemergmed.2004.07.331.
262. Barton ED, Swanson ER, Hutton KC. Success and failure rates of rapid sequence intubation versus non–rapid sequence intubation by air medical providers in 2,853 patients. Ann Emerg Med 2004;44.
263. Domeier RM, Chudnofsky CR, Frederiksen SM, Colone P. The effect of paramedic rapid sequence intubation on outcome in trauma patients. Ann Emerg Med 2004;44. http://dx.doi.org/10.1016/j.annemergmed.2004.07.381.
264. Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ. Mortality and prehospital thrombolysis for acute myocardial infarction: a meta-analysis. JAMA 2000;283:2686-92. http://dx.doi.org/10.1001/jama.283.20.2686.
265. Bair AE, Smith D, Lichty L. Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers. J Emerg Med 2005;28:403-7. http://dx.doi.org/10.1016/j.jemermed.2004.12.008.
266. Lowe L, Sagehorn K, Madsen R. The effect of a rapid sequence induction protocol on intubation success rate in an air medical program. Air Med J 1998;17:101-4. http://dx.doi.org/10.1016/S1067-991X(98)90103-1.
267. Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM. Out-of-hospital endotracheal intubation experience and patient outcomes. Ann Emerg Med 2010;55:527-37. http://dx.doi.org/10.1016/j.annemergmed.2009.12.020.
268. Brown J, Thomas F. What happens with failed blind nasal tracheal intubations?. Air Med J 2001;20:13-6. http://dx.doi.org/10.1016/S1067-991X(01)70093-4.
269. Wang HE, O’Connor RE, Schnyder ME, Barnes TA, Megargel RE. Patient status and time to intubation in the assessment of prehospital intubation performance. Prehosp Emerg Care 2001;5:10-8. http://dx.doi.org/10.1080/10903120190940254.
270. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001;37:32-7. http://dx.doi.org/10.1067/mem.2001.112098.
271. Cooper S, O’Carroll J, Jenkin A, Badger B. Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner – qualitative and summative findings. Emerg Med J 2007;24:625-9. http://dx.doi.org/10.1136/emj.2006.043943.
272. Brown L. Do warning lights and sirens reduce ambulance response times?. Ann Emerg Med 1999;34. http://dx.doi.org/10.1016/S0196-0644(99)80141-3.
273. Cooney DR, Wojcik S, Seth N. 117 Can NEDOCS score be used to predict ambulance offload delay?. Ann Emerg Med 2011;58. http://dx.doi.org/10.1016/j.annemergmed.2011.06.144.
274. Lerner EB, Billittier AJ, Adolf JE. Ambulance, fire, and police dispatch times compared with the atomic clock. Prehosp Emerg Care 2000;4:28-30. http://dx.doi.org/10.1080/10903120090941597.
275. Yeh C, Bloom E, Ramanujam P. A comparison of time to scene response intervals for acute stroke: Is time saved by red lights and siren response?. Ann Emerg Med 2011;1. http://dx.doi.org/10.1016/j.annemergmed.2011.06.398.
276. Gilbert M. Save time, save lives in acute MI: preliminary results from a local community model for early, prehospital thrombolysis in Troms county, Norway. Acta Anaesthesiol Scand Suppl 2001;115.
277. Drew BJ, Sommargren CE, Schindler DM, Benedict K, Zegre-Hemsey J, Glancy JP. A simple strategy improves prehospital electrocardiogram utilization and hospital treatment for patients with acute coronary syndrome (from the ST SMART Study). Am J Cardiol 2011;107:347-52. http://dx.doi.org/10.1016/j.amjcard.2010.09.027.
278. Dhindsa HS, Lovelady J, Nicholson B, Reid R. Does the use of helicopter EMS reduce door to balloon time for STEMI Patients?. Air Med J 2011;30:255-6. http://dx.doi.org/10.1016/j.amj.2011.07.011.
279. Ho J, Casey B. Time saved with use of emergency warning lights and sirens during response to requests for emergency medical aid in an urban environment. Ann Emerg Med 1998;32:585-8. http://dx.doi.org/10.1016/S0196-0644(98)70037-X.
280. Hunt RC, Brown LH, Cabinum ES, Whitley TW, Prasad NH, Owens CF, et al. Is ambulance transport time with lights and siren faster than that without?. Ann Emerg Med 1995;25:507-11. http://dx.doi.org/10.1016/S0196-0644(95)70267-9.
281. Marques-Baptista A, Ohman-Strickland P, Baldino KT, Prasto M, Merlin MA. Utilization of warning lights and siren based on hospital time-critical interventions. Prehosp Disaster Med 2010;25:335-9.
282. O’Brien DJ, Price TG, Adams P. The effectiveness of lights and siren use during ambulance transport by paramedics. Prehosp Emerg Care 1999;3:127-30. http://dx.doi.org/10.1080/10903129908958920.
283. Ho J, Lindquist M. Time saved with the use of emergency warning lights and siren while responding to requests for emergency medical aid in a rural environment. Prehosp Emerg Care 2001;5:159-62. http://dx.doi.org/10.1080/10903120190940056.
284. Frendl DM, Palmeri ST, Clapp JR, Hampton D, Sejersten M, Young D. Overcoming barriers to developing seamless ST-segment elevation myocardial infarction care systems in the United States: recommendations from a comprehensive prehospital 12-lead electrocardiogram working group. J Electrocardiol 2009;42:426-31. http://dx.doi.org/10.1016/j.jelectrocard.2009.03.011.
285. Brown LH, Fowler NH. An evaluation of EMS educational programs in North Carolina. Prehosp Emerg Care 1999;3:157-62. http://dx.doi.org/10.1080/10903129908958925.
286. Batchelder AJ, Steel A, Mackenzie R, Hormis AP, Daniels TS, Holding N. Simulation as a tool to improve the safety of pre-hospital anaesthesia – a pilot study. Anaesthesia 2009;64:978-83. http://dx.doi.org/10.1111/j.1365-2044.2009.05990.x.
287. Thomas F, Rhoades C, Carpenter J, Holleran R, Handrahan D. Difficult airway simulator intubation success rates using commission on accreditation of medical transport systems training standards. Air Med J 2011;30:208-15. http://dx.doi.org/10.1016/j.amj.2010.12.001.
288. Eastwood K, Boyle MJ, Williams B. Mathematical and drug calculation abilities of paramedic students. Emerg Med J 2013;30:241-2. http://dx.doi.org/10.1136/emermed-2011-200929.
289. Lindstrom A. Patient’s clothing ignites during defibrillation. JEMS 2004;29:20-1.
290. Steinbruner D, Mazur R, Mahoney PF. Intracranial placement of a nasopharyngeal airway in a gun shot victim. Emerg Med J 2007;24. http://dx.doi.org/10.1136/emj.2007.046490.
291. Schade K, Borzotta A, Michaels A. Intracranial malposition of nasopharyngeal airway. J Trauma 2000;49:967-8. http://dx.doi.org/10.1097/00005373-200011000-00032.
292. Bultman LL, Mahoney B, Fringer R. Effectiveness of prehospital continuous positive airway pressure in treating adult respiratory distress. Ann Emerg Med 2005;46. http://dx.doi.org/10.1016/j.annemergmed.2005.06.416.
293. Sterba JA. Efficacy and safety of prehospital rewarming techniques to treat accidental hypothermia. Ann Emerg Med 1991;20:896-901. http://dx.doi.org/10.1016/S0196-0644(05)81434-9.
294. Jensen JL, Croskerry C, Travers AH. Consensus on paramedic clinical decisions during high acuity emergency calls: results of a Canadian Delphi study. CJEM 2010;12:229-78.
295. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma 2000;49:584-99. http://dx.doi.org/10.1097/00005373-200010000-00003.
296. Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001;345:631-7. http://dx.doi.org/10.1056/NEJMoa002141.
297. Morales JM, Rodriguez MM, Terol J, Torres A, Alvarez JM. Nursing records with standardized nursing language in prehospital emergency care: from utopia to reality. Int J Nurs Terminol Classif 2003;14. http://dx.doi.org/10.1111/j.1744-618X.2003.032_9.x.
298. Febra C, Lufinha A. Prehospital transcutaneous cardiac pacing in bradycardia and asystole. Crit Care 2005;9. http://dx.doi.org/10.1186/cc3371.
299. Garza AG. Prehospital intubation is associated with increased mortality in primary cardiac arrest patients with ventricular fibrillation. Ann Emerg Med 2006;48. http://dx.doi.org/10.1016/j.annemergmed.2006.07.761.
300. LeBlanc VR, Regehr C, Tavares W, Scott AK, MacDonald R, King K. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med 2012;27:369-74. http://dx.doi.org/10.1017/S1049023X12001021.
301. MacDonald RD, Adhikari NKJ, Scales DC, Wax RS, Stewart TE, Ferguson ND, et al. Outcomes of interfacility critical care adult patient transport: a systematic review. Can J Anaesth 2006;53:A417-18. http://dx.doi.org/10.1007/BF03022513.
302. Patterson PD, Huang DT, Fairbanks RJ, Wang HE. The emergency medical services safety attitudes questionnaire. Am J Med Qual 2010;25:109-15. http://dx.doi.org/10.1177/1062860609352106.
303. American College of Emergency Physicians . EMS as an essential public safety service. Policy statement. Ann Emerg Med 2011;57:313-14. http://dx.doi.org/10.1016/j.annemergmed.2010.11.018.
304. Singh JM, MacDonald RD, Bronskill SE, Schull MJ. Incidence and predictors of critical events during urgent air-medical transport. Can Med Assoc J 2009;181:579-84. http://dx.doi.org/10.1503/cmaj.080886.
305. Ursic C, Curtis K, Zou Y, Black D. Improved trauma patient outcomes after implementation of a dedicated trauma admitting service. Injury 2009;40:99-103. http://dx.doi.org/10.1016/j.injury.2008.06.034.
306. Mariani M, Musso P, Dalmasso M. Feasibility and safety of transferring patients with acute coronary syndrome between hospitals. Trends Med 2008;8:49-54.
307. Hoot NR, Zhou C, Jones I, Aronsky D. Measuring and forecasting emergency department crowding in real time. Ann Emerg Med 2007;49:747-55. http://dx.doi.org/10.1016/j.annemergmed.2007.01.017.
308. Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ 2003;168:277-83.
309. Braithwaite I. Issues in neonatal transport: improving safety for patients and staff. J Neonatal Nurs 2000;6:65-9.
310. Selevan JS, Fields WW, Chen W, Petitti DB, Wolde-Tsadik G. Critical care transport: outcome evaluation after interfacility transfer and hospitalization. Ann Emerg Med 1999;33:33-4. http://dx.doi.org/10.1016/S0196-0644(99)70414-2.
311. Brown LH, Whitney CL, Hunt RC, Addario M, Hogue T. Do warning lights and sirens reduce ambulance response times?. Prehosp Emerg Care 2000;4:70-4. http://dx.doi.org/10.1080/10903120090941696.
312. Low RB, Martin D, Brown C. Emergency air transport of pregnant patients: the national experience. J Emerg Med 1988;6:41-8. http://dx.doi.org/10.1016/0736-4679(88)90250-8.
313. Orthner H. Advanced Communication Infrastructure for Pre-Hospital EMS Care n.d.
314. Widner-Kolberg MR. Immobilizing children in care safety seats – why, when, and how. J Emerg Nurs 1991;17:427-8.
315. Putzer G, Braun P, Zimmermann A, Pedross F, Strapazzon G, Brugger H, et al. LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescue – a prospective, randomized, cross-over manikin study. Am J Emerg Med 2013;31:384-9. http://dx.doi.org/10.1016/j.ajem.2012.07.018.
316. Berg BW, Beamis EK, Murray WB, Boedeker BH. Remote videolaryngoscopy skills training for prehospital personnel. Stud Health Technol Inform 2009;142:31-3.
317. Jones A, Allinson K, Wright H, Porter K. Use of prehospital dressings in soft tissue trauma: is there any conformity or plan?. Emerg Med J 2009;26:532-4.
318. Lobel D, Likourezos A, Farahani C, Podolsky S. Successful implementation of an etomidate-facilitated endotracheal intubation protocol in an urban ground transport ambulance system. Ann Emerg Med 2008;52. http://dx.doi.org/10.1016/j.annemergmed.2008.06.191.
319. Iqbal M, Banerjee S, Spaight A, Stephenson J, Siriwardena AN. Prehospital intravenous cannulation: reducing the risks and rate from inappropriate venous access by paramedics. Emerg Med J 2009;26. http://dx.doi.org/10.1136/emj.2009.075432a.
320. Yaghoubian A, Lewis RJ, Putnam B, De Virgilio C. Reanalysis of Prehospital Intravenous Fluid Administration in Patients With Penetrating Truncal Injury and Field Hypotension n.d.
321. Vilke GM, Tornabene SV, Stepanski B, Shipp HE, Ray LU, Metz MA. Paramedic self-reported medication errors. Prehosp Emerg Care 2007;11:80-4. http://dx.doi.org/10.1080/10903120601021358.
322. Shewakramani S, Harrison TH, Nardelli B, Thomas SH. Adequacy of fluid resuscitation during transport of burn patients. Ann Emerg Med 2006;48. http://dx.doi.org/10.1016/j.annemergmed.2006.07.690.
323. Smith D, Bair AE. Intubation techniques associated with unrecognized nontracheal intubations by out-of-hospital providers. Ann Emerg Med 2003;42:S1-109.
324. Cameron PA, Gabbe B, Bernard S, Mulholland S. Does intubation prehospital improve outcomes for head injured patients. Ann Emerg Med 2005;46. http://dx.doi.org/10.1016/j.annemergmed.2005.06.413.
325. Millikan D, Rice B, Silbergleit R. Emergency treatment of status epilepticus: current thinking. Emerg Med Clin N Am 2009;27:101-13. http://dx.doi.org/10.1016/j.emc.2008.12.001.
326. Birk HO, Henriksen LO. Ambulance-technicians’ indications for prehospital interventions. Prehosp Disaster Med 2002;17.
327. Cameron P, Gabbe B, Finch C, McNeil J, Smith K, Wolfe R. Prehospital predictors of major injury. Prehosp Disaster Med 2002;17:S8-9.
328. Hick JL, Mahoney BD, Lappe M. Prehospital sedation with intramuscular droperidol: a one-year pilot. Prehosp Emerg Care 2001;5:391-4. http://dx.doi.org/10.1080/10903120190939571.
329. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283:783-90. http://dx.doi.org/10.1001/jama.283.6.783.
330. Smith WS, Isaacs M, Corry MD. Accuracy of paramedic identification of stroke and transient ischemic attack in the field. Prehosp Emerg Care 1998;2:170-5. http://dx.doi.org/10.1080/10903129808958866.
331. Nardi G, Massarutti D, Kette F, De Monte A. Pre-hospital care for severe trauma patients: on the field ATLS and helicopter transport are associated with a sharp reduction in mortality. Clin Intensive Care 1995;6.
332. Massarutti D, Trillo G, Berlot G, Tomasini A, Bacer B, D’Orlando L. Simple thoracostomy in prehospital trauma management is safe and effective: A 2-year experience by helicopter emergency medical crews. Eur J Emerg Med 2006;13:276-80. http://dx.doi.org/10.1097/00063110-200610000-00006.
333. Haynes BE, Pritting J. A rural emergency medical technician with selected advanced skills. Prehosp Emerg Care 1999;3:343-6. http://dx.doi.org/10.1080/10903129908958966.
334. Widiatmoko D, Machen I, Dickinson A, Williams J, Kendall S. Developing a new response to non-urgent emergency calls: evaluation of a nurse and paramedic partnership intervention. Prim Health Care Res Dev 2008;9:183-90. http://dx.doi.org/10.1017/S1463423608000765.
335. Schaefer RA, Rea TD, Plorde M, Peiguss K, Goldberg P, Murray JA. An emergency medical services program of alternate destination of patient care. Prehosp Emerg Care 2002;6:309-14. http://dx.doi.org/10.1080/10903120290938355.
336. Anderson BD, Manoguerra AS, Haynes BE. Diversion of 911 poisoning calls to a poison center. Prehosp Emerg Care 1998;2:176-9. http://dx.doi.org/10.1080/10903129808958867.
337. Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003;12:ii17-23. http://dx.doi.org/10.1136/qhc.12.suppl_2.ii17.
338. NPSA . Manchester Patient Safety Framework (MaPSaF) – Acute 2006. www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60013&amp;type=full&amp;servicetype=Attachment (accessed 12 January 2011).
339. Mannion R, Konteh FH, Davies HTO. Assessing organisational culture for quality and safety improvement: a national survey of tools and tool use. Qual Saf Health Care 2009;18:153-6. http://dx.doi.org/10.1136/qshc.2007.024075.
340. Eurocontrol/FAA . Action Plan 15 Safety: Safety Culture in Air Traffic Management – A White Paper n.d. www.eurocontrol.int/safety/gallery/content/public/library/Safety%20Culture/Safety_ATM_WhitePaper_final%20low.pdf (accessed 12 January 2011).
341. Organising for Safety: 3rd Report of the ACSNI Study Group on Human Factors. London: HSE Books; 1993.
342. Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Saf Health Care 2005;14:231-3. http://dx.doi.org/10.1136/qshc.2005.015180.
343. Sexton J, Helmreich R, Neilands T, . The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006;6. http://dx.doi.org/10.1186/1472-6963-6-44.
344. Flin R, Burns C, Mearns K, Yule S, Robertson EM. Measuring safety climate in health care. Qual Saf Health Care 2006;15:109-15. http://dx.doi.org/10.1136/qshc.2005.014761.
345. Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; 2004.
346. MacDonald R, Yelle R, Oake-Vecchiato JA, Melis C, Bigham BL. Derivation of a taxonomy to categorize adverse events and near-misses in transport medicine. Air Med J 2011;30:254-5. http://dx.doi.org/10.1016/j.amj.2011.07.008.
347. Stella J, Davis A, Jennings P, Bartley B. Introduction of a prehospital critical incident monitoring system – pilot project results. Prehosp Disaster Med 2008;23:154-60.
348. Meisel ZF, Hargarten S, Vernick J. Addressing prehospital patient safety using the science of injury prevention and control. Prehosp Emerg Care 2008;12:411-16. http://dx.doi.org/10.1080/10903120802290851.
349. Levick NR, Swanson J. An optimal solution for enhancing ambulance safety: implementing a driver performance feedback and monitoring device in ground emergency medical service vehicles. Annu Proc Assoc Adv Automot Med 2005;49:35-50.
350. O’Connor RE, Slovis CM, Hunt RC, Pirrallo RG, Sayre MR. Eliminating errors in emergency medical services: Realities and recommendations. Prehosp Emerg Care 2002;6:107-13. http://dx.doi.org/10.1080/10903120290938913.
351. O’Connor RE, Megargel RE. The effect of a quality improvement feedback loop on paramedic skills, charting, and behavior. Prehosp Disaster Med 1994;9:35-9.
352. Taking Healthcare to the Patient: Transforming NHS Ambulance Services. London: Department of Health; 2005.
353. Changing times – Sustaining Long-Term Performance Against ‘Call Connect’ for NHS Ambulance Services. London: Department of Health; 2008.
354. A Vision for Emergency and Urgent Care – The Role of Ambulance Services. London: NHS Confederation; 2008.
355. Jones SP, Carter B, Ford GA, Gibson JM, Leathley MJ, McAdam JJ, et al. The identification of acute stroke: an analysis of emergency calls. Int J Stroke 2013;8:408-12. http://dx.doi.org/10.1111/j.1747-4949.2011.00749.x.
356. Beynon-Davies P. Human error and information systems failure: the case of the London ambulance service computer-aided dispatch system project. Interact Comput 1999;11:699-720. http://dx.doi.org/10.1016/S0953-5438(98)00050-2.
357. Ferreira J, Stanley L. Assessment of the Use of Carry Chairs by UK Ambulance Staff n.d.
358. Eckstein M, Chan LS. The impact of emergency department crowding on paramedic ambulance availability. Ann Emerg Med 2003;42:S1-109.
359. Polk JD, Merlino JI, Kovach BL, Mancuso C, Fallon WF. Fetal evaluation for transport by ultrasound performed by air medical teams: a case series. Air Med J 2004;23:32-4. http://dx.doi.org/10.1016/j.amj.2004.04.005.
360. Dahlgren BE, Hogberg R, Nilsson HG. Portable, but suitable: devices in prehospital care might be hazardous to patient or to aviation safety. Prehosp Disaster Med 1997;12:64-7.
361. Crossing the Quality Chasm: A New Healthcare System for the 21st Century. Washington, DC: National Academy Press; 2004.
362. Safe Handover: Safe Patients. London: BMA; 2004.
363. Joint Commission on Accreditation of Healthcare . Focus on five. Strategies to improve hand-off communication: implementing a process to resolve questions. Joint Commission Perspectives on Patient Safety 2005;5.
364. Apker J, Mallak LA, Gibson SC. Communicating in the ‘Gray Zone’: perceptions about emergency physician–hospitalist handoffs and patient safety. Acad Emerg Med 2007;14:884-94.
365. Jeffcott SA, Ibrahim JE, Cameron PA. Resilience in healthcare and clinical handover. Qual Saf Health Care 2009;18:256-60. http://dx.doi.org/10.1136/qshc.2008.030163.
366. Raduma-Tomàs MA, Flin R, Yule S, Williams D. Doctors’ handovers in hospitals: a literature review. BMJ Qual Saf 2011;20:128-33. http://dx.doi.org/10.1136/bmjqs.2009.034389.
367. Wong MC, Yee KC, Turner P. Clinical Handover Literature Review. Sydney, NSW: Australian Commission on Safety and Quality in Healthcare; 2008.
368. Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Clinical handover of patients arriving by ambulance to the emergency department – a literature review. Int Emerg Nurs 2010;18:210-20. http://dx.doi.org/10.1016/j.ienj.2009.11.006.
369. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care 2010;19:493-7. http://dx.doi.org/10.1136/qshc.2009.033480.
370. Patterson WS, Wears RL. Patient handoffs: standardised and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf 2010;36:52-61.
371. Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320:791-4. http://dx.doi.org/10.1136/bmj.320.7237.791.
372. Horwitz L, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med 2006;166:1173-7. http://dx.doi.org/10.1001/archinte.166.11.1173.
373. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 2005;80:1094-9. http://dx.doi.org/10.1097/00001888-200512000-00005.
374. Ye K, McD Taylor D, Knott JC, Dent A, MacBean CE. Handover in the emergency department: deficiencies and adverse effects. Emerg Med Australas 2007;19:433-41. http://dx.doi.org/10.1111/j.1742-6723.2007.00984.x.
375. Talbot R, Bleetman A. Retention of information by emergency department staff at ambulance handover: do standardised approaches work?. Emerg Med J 2007;24:539-42. http://dx.doi.org/10.1136/emj.2006.045906.
376. McFetridge B, Gillespie M, Goode D, Melby V. An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit. Nurs Crit Care 2007;12:261-9. http://dx.doi.org/10.1111/j.1478-5153.2007.00244.x.
377. Catchpole K, Sellers R, Goldman A, McCulloch P, Hignett S. Patient handovers within the hospital: translating knowledge from motor racing to healthcare. Qual Saf Health Care 2010;19:318-22. http://dx.doi.org/10.1136/qshc.2009.026542.
378. Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qual Saf Health Care 2009;18:261-6. http://dx.doi.org/10.1136/qshc.2008.031609.
379. Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Qual Saf Health Care 2009;18:137-40. http://dx.doi.org/10.1136/qshc.2007.025247.
380. Johnson JK, Arora VM. Improving clinical handovers: creating local solutions for a global problem. Qual Saf Health Care 2009;18:244-5. http://dx.doi.org/10.1136/qshc.2009.032946.
381. Bomba D, Prakash R. A description of handover processes in an Australian public hospital. Aust Health Rev 2005;29:68-79. http://dx.doi.org/10.1071/AH050068.
382. McCann L, McHardy K, Child S. Passing the buck: clinical handovers at a tertiary hospital. N Z Med J 2007;120.
383. Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-66. http://dx.doi.org/10.1002/jhm.103.
384. Arora VM, Johnson JK, Meltzer DO, Humphrey HJ. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care 2008;17:11-4. http://dx.doi.org/10.1136/qshc.2006.018952.
385. Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care 2009;18:248-55. http://dx.doi.org/10.1136/qshc.2008.028654.
386. Cleland JA, Ross S, Miller SC, Patey R. ‘There is a chain of Chinese whispers . . .’: empirical data support the call to formally teach handover to prequalification doctors. Qual Saf Health Care 2009;18:267-71. http://dx.doi.org/10.1136/qshc.2008.029983.
387. Cheung DS, Kelly JJ, Beach C, Berkeley RP, Bitterman RA, Broida RI, et al. Improving handoffs in the emergency department. Ann Emerg Med 2010;55:171-80. http://dx.doi.org/10.1016/j.annemergmed.2009.07.016.
388. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005;14:401-7. http://dx.doi.org/10.1136/qshc.2005.015107.
389. Arora V, Julia K, Lovinger D, Seiden SC, Meltzer D. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med 2007;200:1751-5. http://dx.doi.org/10.1007/s11606-007-0415-x.
390. Rehn M, Vigerust T, Andersen JE, Krüger AJ, Lossius HM. Major incident patient evacuation: full-scale field exercise feasibility study. Air Med J 2011;30:153-7. http://dx.doi.org/10.1016/j.amj.2011.01.005.
391. Sillesen M, Sejersten M, Strange S, Clemmensen P. Telemedical Transmission of Prehospital ECG’s in Patients With Acute Chest Pain n.d.
392. Sujan MA, Chessum P, Rudd M, Fitton L, Inada-Kim M, Spurgeon P, et al. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J 2015;32:112-8. http://dx.doi.org/10.1136/emermed-2013-202977.
393. National Health Service Act 2006. London: The Stationery Office; 2006.
394. Monitor . NHS Foundation Trust Annual Reporting Manual 2011 12 2012. www.monitor-nhsft.gov.uk/sites/default/files/Annual_Reporting_Manual_2011-12%20-%20final_2.pdf (accessed 21 May 2014).
395. Department of Health . Quality Accounts Toolkit 2010 11 – Advisory Guidance for Providers of NHS Services Producing Quality Accounts for the Year 2010 11 2010. www.gov.uk/government/uploads/system/uploads/attachment_data/file/216185/dh_122540.pdf (accessed 21 May 2014).
396. National Patient Safety Agency . Organisation Patient Safety Incident Reports n.d. www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incident-reports/ (accessed 21 June 2012).
397. National Patient Safety Agency . Organisation Patient Safety Incident Reports n.d. www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incident-reports/directory/?q=0%C2%ACambulance%C2%AC (accessed 13 May 2012).
398. Wang HE, Fairbanks RJ, Shah MN, Abo BN, Yealy DM. Tort claims and adverse events in emergency medical services. Ann Emerg Med 2008;52:256-62. http://dx.doi.org/10.1016/j.annemergmed.2008.02.011.
399. Clark JR. Delay in Treatment. Air Med J 2011;30:117-19. http://dx.doi.org/10.1016/j.amj.2011.03.001.
400. Policy paper . Summary of Reports and Responses under Rule 43 of the Coroners Rules n.d. www.justice.gov.uk/publications/policy/moj/summary-of-reports-and-responses-under-rule-43-of-the-coroners-rules (accessed 7 November 2011).
401. National Health Service National Staff Survey. 2011. Essex: Data Archive [distributor]; 2013.
402. Paul CL. A modified Delphi approach to a new card sorting methodology. Journal of Usability Studies 2008;4:7-30.
403. Taylor-Adams S, Vincent C. System Analysis of Clinical Incidents: The London Protocol. Imperial College London, London: Clinical Safety Research Unit; 2012.
404. Lawton R, McEachan RRC, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf 2012. http://dx.doi.org/10.1136/bmjqs-2011-000443.
405. Edmondson AC. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behavl Sci 1996;32:5-28. http://dx.doi.org/10.1177/0021886396321001.
406. Stymiest DL. Joining forces. Integrating utility and emergency management for better patient safety. Health Facil Manage 2003;16:26-9.
407. Stoop JA. Independent accident investigation: a modern safety tool. J Hazard Mater 2004;111:39-44. http://dx.doi.org/10.1016/j.jhazmat.2004.02.006.
408. Danielson NE. EtO Emergency. Think safety before a spill. Mater Manag Health Care 1998;7.
409. McNamara R, Yu DK, Kelly JJ. Public perception of safety and metal detectors in an urban emergency department. Am J Emerg Med 1997;15:40-2. http://dx.doi.org/10.1016/S0735-6757(97)90045-0.
410. Thompson MR. The three Rs of fire safety, emergency action, and fire prevention planning: promoting safety at the worksite. AAOHN J 2003;51:169-79.
411. Hawkins MR. National Flight Nurses Association . NFNA safety survey: a report of data collected in 1988 versus 1998. Air Med J 2000;19:128-33. http://dx.doi.org/10.1016/S1067-991X(00)90002-6.
412. Bottle A, Aylin P. Application of AHRQ patient safety indicators to English hospital data. Qual Saf Health Care 2009;18:303-8. http://dx.doi.org/10.1136/qshc.2007.026096.
413. Van De Velde M, Kuypers M, Teunkens A, Devroe S. Risk and safety of anesthesia outside the operating room. Minerva Anestesiol 2009;75:345-8.
414. Lundstrom T, Pugliese G, Bartley J, Cox J, Guither C. Organizational and environmental factors that affect worker health and safety and patient outcomes. Am J Infect Control 2002;30:93-106. http://dx.doi.org/10.1067/mic.2002.119820.
415. Rall M, Dieckmann P. Safety culture and crisis resource management in airway management: general principles to enhance patient safety in critical airway situations. Best Pract Res Clin Anaesthesiol 2005;19:539-57. http://dx.doi.org/10.1016/j.bpa.2005.07.005.
416. Vaast P, Puech F. Safety of patient transport for in utero fetal indication. J Gynecol Obstet Biol Reprod (Paris) 2001;30:S25-8.
417. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med 2004;11:1341-5. http://dx.doi.org/10.1111/j.1553-2712.2004.tb01925.x.
418. Anonymous . Strategies to improve patient and healthcare provider safety in patient handling and movement tasks. Rehabil Nurs 2005;30:80-3. http://dx.doi.org/10.1002/j.2048-7940.2005.tb00366.x.
419. Flannery RB. Theories of human violence: implications for health care safety. Int J Emerg Ment Health 2004;6:105-10.
420. McDaniel L. Is your facility’s emergency response strategy updated?. Biomed Instrum Technol 2005;39:413-5.
421. McLaughlin N. First, do no harm. Patient welfare should come first in flight and legislation. Mod Healthc 2008;38.
422. Cosby KS, Croskerry P. Patient safety: a curriculum for teaching patient safety in emergency medicine. Acad Emerg Med 2003;10:69-78. http://dx.doi.org/10.1111/j.1553-2712.2003.tb01981.x.
423. Valentin J. International Commission on Radiation Protection . Prevention of high-dose-rate brachytherapy accidents. ICRP Publication 97. Ann ICRP 2005;35:1-51.
424. Kahn LH. Biodefense research: can secrecy and safety coexist?. Biosecur Bioterror 2004;2:81-5. http://dx.doi.org/10.1089/153871304323146379.
425. Balonov M. International Atomic Energy Agency . Exposures from environmental radioactivity: international safety standards. Appl Radiat Isot 2008;66:1546-9. http://dx.doi.org/10.1016/j.apradiso.2007.10.013.
426. Burkle FM, Hayden R. The concept of assisted management of large-scale disasters by horizontal organizations. Prehospital Disaster Med 2001;16:128-37.
427. Anonymous . Emergency management standards clarified. Jt Comm Perspect 2002;22.
428. Jessup R. ERG: an essential first responder resource. Occup Health Saf 2008;77.
429. Sudakin DL, Trevathan WR. DEET: a review and update of safety and risk in the general population. J Toxicol Clin Toxicol 2003;41:831-9. http://dx.doi.org/10.1081/CLT-120025348.
430. Osimitz TG, Grothaus RH. The present safety assessment of DEET. J Am Mosq Control Assoc 1995;11:274-8.
431. Garcia J. A call to action. JEMS 2002;27.
432. Benson NH, Hunt RC, Tolson J, Stone CK, Sousa JA, Nimmo MJ. Improved flight following through continuous quality improvement. Air Med J 1994;13:163-5. http://dx.doi.org/10.1016/S1067-991X(05)80107-5.
433. MacDonald E. Knowing our limits. Air Med J 2009;28. http://dx.doi.org/10.1016/j.amj.2009.04.014.
434. Wiwanitkit V. Transport nurse safety practice: requirement in developing countries. Air Med J 2010;29. http://dx.doi.org/10.1016/j.amj.2009.12.001.
435. Shanaberger CJ. Field operations and written policy. What you do not know can hurt you. Greater Houston Transport v Zrubeck. J Emerg Med Serv JEMS 1993;18.
436. Zigmond J. Flying in the face of danger. A spate of air ambulance crashes has raised questions about safety, but providers say the service offers overwhelming benefits. Modern Healthcare 2008;38:6-7.
437. Slattery DE, Silver A. The hazards of providing care in emergency vehicles: an opportunity for reform. Prehosp Emerg Care 2009;13:388-97. http://dx.doi.org/10.1080/10903120802706104.
438. MacDonald E, Heffernan J. Safety above all: an Air Medical Safety Advisory Council update. Air Med J 2002;21:15-6. http://dx.doi.org/10.1016/S1067-991X(02)70049-7.
439. Jagim M, Wylie MA. Slam on the brakes. How EMS providers can prevent motor vehicle injuries. J Emerg Med Serv JEMS 1997;22:84-6.
440. Waller PF. Challenges in motor vehicle safety. Annu Rev Public Health 2002;23:93-113. http://dx.doi.org/10.1146/annurev.publhealth.23.100901.140522.
441. Simsic JM, Masterson K, Kogon BE, Kirshbom PM, Kanter KR. Pre-hospital discharge car safety seat testing in infants following congenital heart surgery. Pediatric Cardiology 2008;29:313-16. http://dx.doi.org/10.1007/s00246-007-9021-2.
442. Nordberg M. Improving ambulance safety. Emerg Med Serv 2006;35.
443. Batchelor T. A step toward safety. NIOSH study shows improved reach in Winter Park ambulance design. EMS Magazine 2009;38:71-2.
444. Erich J. Ambulance safety: what’s new, what’s needed. Emerg Med Serv 2002;31:51-4.
445. Levick N. Rig safety 9-1-1: what you need to know about ambulance safety &amp; standards. J Emerg Med Serv JEMS 2008;33:66-7. http://dx.doi.org/10.1016/S0197-2510(08)70380-2.
446. Lutz S. Professionals seek improved air ambulance safety record. Mod Healthc 1987;17.
447. Amintabish S. Fire safety in health care facilities. J Acad Hosp Adm 1997;9:55-62.
448. Barbey JT, Roose SP. SSRI safety in overdose. J Clin Psychiatry 1998;59:42-8.
449. Kroesen GA. Risks and safety standards of flying intensive care units. Acta Anaesthesiol Scand Suppl 1996;109:108-9.
450. Errando CL, Blasco P. Drug administration errors in departments of anaesthesiology, intensive care recovery, and emergency: improving safety and quality assurance. Rev Esp Anestesiol Reanim 2006;53:397-9.
451. Goupil MT. Occupational health and safety emergencies. Dent Clin North Am 1995;39:637-47.
452. McCusker J, Roberge D, Vadeboncoeur A, Verdon J. Safety of discharge of seniors from the emergency department to the community. Healthc Q 2009;12:24-32. http://dx.doi.org/10.12927/hcq.2009.20963.
453. Sklar DP, Crandall CS, Zola T, Cunningham R. Emergency physician perceptions of patient safety risks. Ann Emerg Med 2010;55:336-40. http://dx.doi.org/10.1016/j.annemergmed.2009.08.020.
454. Hohenhaus SM. Leading the revolution: supporting and sustaining a culture of safety in the emergency department. J Emerg Nurs 2009;35:354-5. http://dx.doi.org/10.1016/j.jen.2009.03.008.
455. Hicks CM, Bandiera GW, Denny CJ. Building a simulation-based crisis resource management course for emergency medicine, phase 1: Results from an interdisciplinary needs assessment survey. Acad Emerg Med 2008;15:1136-43. http://dx.doi.org/10.1111/j.1553-2712.2008.00185.x.
456. Barata IA, Benjamin LS, Mace SE, Herman MI, Goldman RD. Pediatric patient safety in the prehospital/emergency department setting. Pediatr Emerg Care 2007;23:412-18. http://dx.doi.org/10.1097/01.pec.0000278393.32752.9f.
457. Brown M. Medication safety issues in the emergency department. Crit Care Nurs Clin North Am 2005;17:65-9. http://dx.doi.org/10.1016/j.ccell.2004.09.009.
458. Cadwell SM. Pediatric medication safety in the emergency department. J Emerg Nurs 2008;34:375-7. http://dx.doi.org/10.1016/j.jen.2008.04.014.
459. O’Neill KA, Shinn D, Starr KT, Kelley J. Patient misidentification in a pediatric emergency department: patient safety and legal perspectives. Pediatr Emerg Care 2004;20:487-92. http://dx.doi.org/10.1097/01.pec.0000136895.99271.86.
460. Ferns T, Cork A, Rew M. Personal safety in the accident and emergency department. Br J Nurs 2005;14:725-30. http://dx.doi.org/10.12968/bjon.2005.14.13.18458.
461. Nelstrop L, Chandler-Oatts J, Bingley W, Bleetman T, Corr F, Cronin-Davis J, et al. A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments. Worldviews Evid Based Nurs 2006;3:8-18. http://dx.doi.org/10.1111/j.1741-6787.2006.00041.x.
462. Schenkel S. Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med 2000;7:1204-22. http://dx.doi.org/10.1111/j.1553-2712.2000.tb00466.x.
463. Campbell SG, Croskerry P, Bond WF. Profiles in patient safety: A ‘perfect storm’ in the emergency department. Acad Emerg Med 2007;14:743-9.
464. Chamberlain JM, Slonim A, Joseph JG. Reducing errors and promoting safety in pediatric emergency care. Ambul Pediatr 2004;4:55-63. http://dx.doi.org/10.1367/1539-4409(2004)004&lt;0055:REAPSI&gt;2.0.CO;2.
465. Ciesielski G, Clark N. Safety in the emergency department: it’s about time. Kans Nurse 2007;82:3-6.
466. Manno EM. Safety issues and concerns for the neurological patient in the emergency department. Neurocrit Care 2008;9:259-64. http://dx.doi.org/10.1007/s12028-008-9111-x.
467. Taylor TB. Threats to the health care safety net. Acad Emerg Med 2001;8:1080-7. http://dx.doi.org/10.1111/j.1553-2712.2001.tb01119.x.
468. Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual Health Care 2005;17:5-13. http://dx.doi.org/10.1093/intqhc/mzi006.
469. Adams JG, Biros MH. The endangered safety net: establishing a measure of control. Acad Emerg Med 2001;8:1013-15. http://dx.doi.org/10.1111/j.1553-2712.2001.tb01106.x.
470. Anonymous . JCAHO’s safety goals – the clock is ticking, will your ED be compliant?. ED Manag 2005;17:73-5.
471. Anonymous . ENA study cites barriers to NPSG compliance. ED Manag 2009;21:45-6.
472. Cone DC, Davidson SJ. Hazardous materials preparedness in the emergency department. Prehosp Emerg Care 1997;1:85-90. http://dx.doi.org/10.1080/10903129708958794.
473. Friedland LR. Universal precautions and safety devices which reduce the risk of occupational exposure to blood-borne pathogens: a review for emergency health care workers. Pediatr Emerg Care 1991;7:356-62. http://dx.doi.org/10.1097/00006565-199112000-00010.
474. Anonymous . This year, surveyors to look for patient flow problems: identify bottlenecks now. Hosp Peer Rev 2005;30:1-5.
475. Anonymous . Joint Commission’s 2007 National Patient Safety Goals will revamp emergency department nursing practice. Hosp Case Manag 2006;14:142-4.
476. Australasian College for Emergency Medicine . Violence in emergency departments. Emerg Med Australas 2004;16. http://dx.doi.org/10.1111/j.1742-6723.2004.00604.x.
477. Shaw KN, Ruddy RM, Olsen CS, Lillis KA, Mahajan PV, Dean JM, et al. Pediatric patient safety in emergency departments: unit characteristics and staff perceptions. Pediatrics 2009;124:485-93. http://dx.doi.org/10.1542/peds.2008-2858.
478. McKinley A. Health care providers and facilities issue brief: health facilities: year end report – 2004. Issue Brief Health Policy Track Serv n.d.:1-12.
479. Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, et al. Hospital employee assault rates before and after enactment of the California hospital safety and security act. Ann Epidemiol 2009;19:125-33. http://dx.doi.org/10.1016/j.annepidem.2008.10.009.
480. Dixon-Woods M. Why is patient safety so hard? A selective review of ethnographic studies. J Health Serv Res Policy 2010;15:11-6. http://dx.doi.org/10.1258/jhsrp.2009.009041.
481. Griffin E. Effective systems documentation: essential for safety management. J Healthc Qual 1995;17:26-7. http://dx.doi.org/10.1111/j.1945-1474.1995.tb00776.x.
482. Kennedy TJT, Regehr G, Baker GR, Lingard LA. ‘It’s a cultural expectation . . .’ The pressure on medical trainees to work independently in clinical practice. Med Educ 2009;43:645-53. http://dx.doi.org/10.1111/j.1365-2923.2009.03382.x.
483. Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004;99:2051-7. http://dx.doi.org/10.1111/j.1572-0241.2004.40017.x.
484. Leonidas T. Balance of power. 5 steps to creating an emergency power master plan. Health Facil Manage 2004;17:20-4.
485. Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L. Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care 2009;47:23-31. http://dx.doi.org/10.1097/MLR.0b013e31817e189d.
486. Oakley J. Simplifying the management of the environment of care. Radiol Manage 1997;19:33-41.
487. Lucas AJ. Improving medication safety in a neonatal intensive care unit. Am J Health-Syst Pharm 2004;61:33-7.
488. McCarthy PM, Gaucher KA. Fire in the OR – developing a fire safety plan. AORN J 2004;79:588-97. http://dx.doi.org/10.1016/S0001-2092(06)60910-1.
489. Farah RA, Aquino VM, Munoz LL, Sandler ES. Safety and cost-effectiveness of outpatient total body irradiation in pediatric patients undergoing stem cell transplantation. J Pediatr Hematol Oncol 1998;20:319-21. http://dx.doi.org/10.1097/00043426-199807000-00007.
490. Maggiore WA, Palmer RB. Exercise restraint. Medical &amp; legal issues you must understand to protect the patient &amp; yourself. JEMS 2002;27:84-8.
491. Takada S. Principles of chemotherapy safety procedures. Clin Tech Small Anim Pract 2003;18:73-4. http://dx.doi.org/10.1053/svms.2003.36618.
492. Benveniste KA, Hibbert PD, Runciman WB. Violence in health care: the contribution of the Australian Patient Safety Foundation to incident monitoring and analysis. Med J Aust 2005;183:348-51.
493. Brasic JR, Fogelman D. Clinician safety. Psychiatr Clin North Am 1999;22:923-40. http://dx.doi.org/10.1016/S0193-953X(05)70134-9.
494. Johnston T, Moser R, Moeller K, Moriarty TM. Intraoperative MRI: safety. Neurosurg Clin N Am 2009;20:147-53. http://dx.doi.org/10.1016/j.nec.2009.04.007.
495. Mohammed NB, NoorAli R, Anandakumar C, Qureshi RN, Luby S. Management trend and safety of vaginal delivery for term breech fetuses in a tertiary care hospital of Karachi, Pakistan. J Perinat Med 2001;29:250-9. http://dx.doi.org/10.1515/JPM.2001.036.
496. Moore EE. Acute care surgery: the safety net hospital model. Surgery 2007;141:297-8. http://dx.doi.org/10.1016/j.surg.2007.01.004.
497. Asplin BR. Tying a knot in the unravelling health care safety net. Acad Emerg Med 2001;8:1075-9. http://dx.doi.org/10.1111/j.1553-2712.2001.tb01118.x.
498. Bremner JD, Wingard P, Walshe TA. Safety of mirtazapine in overdose. J Clin Psychiatry 1998;59:233-5. http://dx.doi.org/10.4088/JCP.v59n0505.
499. Krug SE. The art of communication: strategies to improve efficiency, quality of care and patient safety in the emergency department. Pediatr Radiol 2008;38:S655-9. http://dx.doi.org/10.1007/s00247-008-0893-y.
500. Scalise D. Six sigma in action. Case studies in quality put theory into practice. Hosp Health Netw 2003;77:57-62.
501. Weller JM, Merry AF, Robinson BJ, Warman GR, Janssen A. The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial. Anaesthesia 2009;64:126-30. http://dx.doi.org/10.1111/j.1365-2044.2008.05743.x.
502. Goldmann D, Kaushal R. Time to tackle the tough issues in patient safety. Pediatrics 2002;110:823-6. http://dx.doi.org/10.1542/peds.110.4.823.
503. Garnerin P, Pellet-Meier B, Chopard P, Perneger T, Bonnabry P. Measuring human-error probabilities in drug preparation: a pilot simulation study. Eur J Clin Pharmacol 2007;63:769-76. http://dx.doi.org/10.1007/s00228-007-0319-z.
504. Stahel PF, Fakler JKM, Flierl MA, Moldenhauer K, Mehler PS. Current concepts of patient safety: rapid response system. Unfallchirurg 2010;113:239-46. http://dx.doi.org/10.1007/s00113-009-1734-7.
505. Stahel PF, Mehler PS. Medical emergency teams and rapid response triggers – the ongoing quest for the ‘perfect’ patient safety system. Crit Care 2009;13. http://dx.doi.org/10.1186/cc8052.
506. Moldenhauer K, Sabel A, Chu ES, Mehler PS. Clinical triggers: an alternative to a rapid response team. Jt Comm J Qual Patient Saf 2009;35:164-74.
507. Lamont T, Luettel D, Scarpello J, O’Driscoll BR, Connew S. Improving the safety of oxygen therapy in hospitals: summary of a safety report from the National Patient Safety Agency. BMJ 2010;340. http://dx.doi.org/10.1136/bmj.c187.
508. Ma P-l, Xi X-m, Lin H-y, Xu Y, Du B, Zhao H-l, et al. Prospective, multi-centre investigation on safety of critical patients in intensive care units. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2007;19:614-18.
509. Benjamin DM. Reducing medication errors and increasing patient safety: case studies in clinical pharmacology. J Clin Pharmacol 2003;43:768-83. http://dx.doi.org/10.1177/0091270003254794.
510. Marken PA, Pies RW. Emerging treatments for bipolar disorder: safety and adverse effect profiles. Ann Pharmacother 2006;40:276-85. http://dx.doi.org/10.1345/aph.1G112.
511. Basch EM, Servoss JC, Tedrow UB. Safety assurances for dietary supplements policy issues and new research paradigms. J Herbal Pharmacother 2005;5:3-15.
512. Exadaktylos AK, Haffejee F, Wood D, Erasmus P. South African Red Cross Flying Doctors Service quality and safety in the rural and remote South African environment. Aust J Rural Health 2005;13:106-10. http://dx.doi.org/10.1111/j.1440-1854.2005.00663.x.
513. Ciarlet M, Schodel F. Development of a rotavirus vaccine: clinical safety, immunogenicity, and efficacy of the pentavalent rotavirus vaccine, RotaTeq. Vaccine 2009;27:G72-81. http://dx.doi.org/10.1016/j.vaccine.2009.09.107.
514. Novoa AM, Perez K, Borrell C. Evidence-based effectiveness of road safety interventions: a literature review. Gac Sanit 2009;23.
515. Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 2009;22:207-14. http://dx.doi.org/10.1097/ACO.0b013e328324f82d.
516. Velianoff GD. Overcrowding and diversion in the emergency department: the health care safety net unravels. Nurs Clin North Am 2002;37:59-66. http://dx.doi.org/10.1016/S0029-6465(03)00082-3.
517. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003;20:402-5. http://dx.doi.org/10.1136/emj.20.5.402.
518. Miller K. Pharmacological management of hypertension in paediatric patients. A comprehensive review of the efficacy, safety and dosage guidelines of the available agents. Drugs 1994;48:868-87. http://dx.doi.org/10.2165/00003495-199448060-00004.
519. Wozniak EJ, Wisser J, Schwartz M. Venomous adversaries: a reference to snake identification, field safety, and bite-victim first aid for disaster-response personnel deploying into the hurricane-prone regions of North America. Wilderness Environ Med 2006;17:246-66. http://dx.doi.org/10.1580/06-WEME-CO-005R.1.
520. Woudenberg F, van der Torn P. Emergency exposure limits: a guide to quality assurance and safety. Qual Assur 1992;1:249-93.
521. Woolf AD. Safety evaluation and adverse events monitoring by poison control centers: a framework for herbs &amp; dietary supplements. Clin Toxicol 2006;44:617-22. http://dx.doi.org/10.1080/15563650600795578.
522. Welles WL, Wilburn RE, Ehrlich JK, Floridia CM. New York hazardous substances emergency events surveillance: learning from hazardous substances releases to improve safety. J Hazard Mater 2004;115:39-4. http://dx.doi.org/10.1016/j.jhazmat.2004.05.009.
523. Van Tilburg C. Backcountry snowboarding: medical and safety aspects. Wilderness Environ Med 1996;7:225-31. http://dx.doi.org/10.1580/1080-6032(1996)007[0225:BSMASA]2.3.CO;2.
524. Isbister JP. The risk/benefit equation for therapeutic plasma exchange. Analysis of the rationale for and the safety aspects of therapeutic plasma exchange. Curr Stud Hematol Blood Transfus 1990;57:10-3.
525. Jaffe KM. Paediatric trauma rehabilitation: a value-added safety net. J Trauma 2008;64:819-23. http://dx.doi.org/10.1097/TA.0b013e318165f177.
526. Kelly DL, Conley RR, Carpenter WT. First-episode schizophrenia: a focus on pharmacological treatment and safety considerations. Drugs 2005;65:1113-38. http://dx.doi.org/10.2165/00003495-200565080-00006.
527. Kleiman NS. Primary and secondary safety endpoints from IMPACT II. Integrilin to Minimise Platelet Aggregation and Coronary Thrombosis. Am J Cardiol 1997;80:29B-33B. http://dx.doi.org/10.1016/S0002-9149(97)00574-2.
528. Kleindorfer PR, Elliott MR, Wang Y, Lowe RA. Drivers of accident preparedness and safety: evidence from the RMP Rule. J Hazard Mater 2004;115:9-16. http://dx.doi.org/10.1016/j.jhazmat.2004.06.016.
529. Kopaladze RA. Methods for the euthanasia of experimental animals – the ethics, esthetics and personnel safety. Usp Fiziol Nauk 2000;31:79-90.
530. Lode H. Safety and tolerability of commonly prescribed oral antibiotics for the treatment of respiratory tract infections. Am J Med 2010;123:S26-38. http://dx.doi.org/10.1016/j.amjmed.2010.02.004.
531. Ta VM, Frattaroli S, Bergen G, Gielen AC. Evaluated community fire safety interventions in the United States: a review of current literature. J Community Health 2006;31:176-97. http://dx.doi.org/10.1007/s10900-005-9007-z.
532. Quail MT, Shannon MW. Pralidoxime safety and toxicity in children. Prehosp Emerg Care 2007;11:36-41. http://dx.doi.org/10.1080/10903120601023289.
533. Pellatt GC. The safety and dignity of patients and nurses during patient handling. Br J Nurs 2005;14:1150-6. http://dx.doi.org/10.12968/bjon.2005.14.21.20076.
534. Read JS, Newell MK. Efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1. Cochrane Database Syst Rev 2005;4.
535. Guise J-M, Lowe NK, Connell L. Patient safety in obstetrics: what aviators, firefighters and others can teach us. Nurs Womens Health 2008;12:208-15. http://dx.doi.org/10.1111/j.1751-486X.2008.00325.x.
536. Saizonou J, De Brouwere V, Vangeenderhuysen C, Dramaix-Wilmet M, Buekens P, Dujardin B. Audit of the quality of treatment of “near miss” patients in referral maternities in Southern Benin. Sante 2006;16:33-42.
537. Dart RC, Green JL, Bogdan GM. The safety profile of sustained release paracetamol during therapeutic use and following overdose. Drug Saf 2005;28:1045-56. http://dx.doi.org/10.2165/00002018-200528110-00005.
538. Bratton RL. Advising patients about international travel. What they can do to protect their health and safety. Postgrad Med 1999;106:57-64. http://dx.doi.org/10.3810/pgm.1999.07.605.
539. Conwit RA, Hart RG, Moy CS, Marler JR. Data and safety monitoring in clinical research: a National Institute of Neurologic Disorders and Stroke perspective. Ann Emerg Med 2005;45:388-92. http://dx.doi.org/10.1016/j.annemergmed.2004.08.006.
540. Jones CT. Annual administrative reviews: safety. Hospitals 1973;47:101-2.
541. Joseph AP, Hunyor SN. The Royal North Shore Hospital inquiry: an analysis of the recommendations and the implications for quality and safety in Australian public hospitals. Med J Aust 2008;188:469-72.
542. Pringle R. Safety of surgery in elderly. Ann Acad Med Singapore 1991;20:260-4.
543. Tiguert R, Rigaud J, Fradet Y. Safety and outcome of early catheter removal after radical retropubic prostatectomy. Urology 2004;63:513-17. http://dx.doi.org/10.1016/j.urology.2003.10.042.
544. Nadzam D, Westergaard F. Pediatric safety in the emergency department: identifying risks and preparing to care for child and family. J Nurs Care Qual 2008;23:189-94. http://dx.doi.org/10.1097/01.NCQ.0000324580.82428.70.
545. Sorra JS, Dyer N. Multilevel psychometric properties of the AHRQ hospital survey on patient safety culture. BMC Health Serv Res 2010;10. http://dx.doi.org/10.1186/1472-6963-10-199.
546. Barer AS. Medical aspect of cosmonauts’ safety during emergency landing. Respicere et prospicere. Aviakosm Ekolog Med 2008;42:3-20.
547. Timmermann A. Modern airway management – current concepts for more patient safety. Anasthesiol Intensivmed Notfallmed Schmerzther 2009;44:246-55. http://dx.doi.org/10.1055/s-0029-1222432.
548. Tice MA. Patient safety: honoring advanced directives. Home Healthc Nurse 2007;25:79-81. http://dx.doi.org/10.1097/00004045-200702000-00005.
549. Faddy SC, Garlick SR. A systematic review of the safety of analgesia with 50% nitrous oxide: can lay responders use analgesic gases in the prehospital setting?. Emerg Med J 2005;22:901-8. http://dx.doi.org/10.1136/emj.2004.020891.
550. Schwaab B, Katalinic A, Riedel J, Sheikhzadeh A. Pre-hospital diagnosis of myocardial ischaemia by telecardiology: safety and efficacy of a 12-lead electrocardiogram, recorded and transmitted by the patient. J Telemed Telecare 2005;11:41-4. http://dx.doi.org/10.1258/1357633053430412.
551. Oemrawsingh PV, Bosker HA, Manger CV, van der LA, Bruschke AV. Safety and efficacy of thrombolysis during ambulance transportation of patients with an acute heart infarct. Ned Tijdschr Geneeskd 1989;133:354-8.
552. Barry J. The HoverMatt system for patient transfer: enhancing productivity, efficiency, and safety. J Nurs Adm 2006;36:114-17. http://dx.doi.org/10.1097/00005110-200603000-00003.
553. Schneider C, Gomez M, Lee R. Evaluation of ground ambulance, rotor-wing, and fixed-wing aircraft services. Crit Care Clin 1992;8:533-64.
554. Wilson P. Fasten their seatbelts: legal restraint of children in car seats and road ambulances. Paediatr Nurs 2007;19:14-8. http://dx.doi.org/10.7748/paed2007.09.19.7.14.c4451.
555. Cox K. When angels fly with eagles: safety as a culture. Air Med J 2002;21:17-22. http://dx.doi.org/10.1016/S1067-991X(02)70081-3.
556. O’Neil J, Yonkman J, Talty J, Bull MJ. Transporting children with special health care needs: comparing recommendations and practice. Pediatrics 2009;124:596-603. http://dx.doi.org/10.1542/peds.2008-1124.
557. Hearns S, Shirley PJ. Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems. Emerg Med J 2006;23:943-7. http://dx.doi.org/10.1136/emj.2006.038075.
558. Vidacovich B. From idea to innovation: tips for engineering safety, comfort &amp; communications into your next ambulance. JEMS 2008;33:60-6. http://dx.doi.org/10.1016/S0197-2510(08)70160-8.
559. Benedek DM, Fullerton C, Ursano RJ. First responders: mental health consequences of natural and human-made disasters for public health and public safety workers. Annu Rev Public Health 2007;28:55-68. http://dx.doi.org/10.1146/annurev.publhealth.28.021406.144037.
560. Frakes MA, Kelly JG. A survey of adherence to community-generated safety guidelines in rotor-wing air medical programs. Air Med J 2007;26:100-3. http://dx.doi.org/10.1016/j.amj.2006.06.039.
561. Davis J. Medical errors and patient safety. Issue brief. Issue Brief Health Policy Track Serv 2010:1-36.
562. Semonin-Holleran R. Ambulance safety: is it an emergency nursing problem?. J Emerg Nurs 2008;34:98-9. http://dx.doi.org/10.1016/j.jen.2008.02.005.
563. Limmer D. 10 commandments for EMS survival. JEMS 2000;25:24-30.
564. McClincy WD. Manufacturing an EMS response. Emerg Med Serv 1999;28:67-9.
565. McLaughlin S. Ready for anything. A look at the Joint Commission’s new emergency management standards. Health Facil Manage 2007;20:39-40.
566. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 2009;53:143-51. http://dx.doi.org/10.1111/j.1399-6576.2008.01717.x.
567. Rischitelli G, Harris J, McCauley L, Gershon R, Guidotti T. The risk of acquiring hepatitis B or C among public safety workers: a systematic review. Am J Prev Med 2001;20:299-306. http://dx.doi.org/10.1016/S0749-3797(01)00292-6.
568. Garrison HG. Feasibility for an EMS workforce safety and health surveillance system. Ann Emerg Med 2007;50:711-14. http://dx.doi.org/10.1016/j.annemergmed.2007.10.010.

Appendix 1 Rapid evidence synthesis

A preliminary search of the evidence on patient safety in the ambulance service

Introduction

The costs of medical errors are considerable at both a personal and an institutional level. 1 It is estimated that 1 in 10 patients in UK hospitals suffers an AE1 yet 50% of such incidents could be avoided if lessons had been learnt from previous incidents. 2

The publication of two seminal reports, To Err is Human: Building a Safer Health System3 and An Organisation with a Memory,4 10 years ago highlighted the fact that there was an urgent need to understand systematically the extent and nature of harm that patients suffer during their contact with health-care services. This gave rise to a surge in research papers in the following years that aimed to quantify the incidence of harm, predominantly in hospital-based care. This was followed by more qualitative studies that tried to understand the mechanisms for failure that give rise to patient harm. Soon it was realised that the underlying attitudes and assumptions about failures and safety within the NHS and health-care in general were a serious obstacle to sustainable improvements in patient safety. The quantification of the safety culture (i.e. the safety-related attitudes, values and beliefs of staff) of an organisation and the development of a systems-oriented safety culture became a second major aim with an increasing number of both quantitative and qualitative papers in the field. We are now at the stage when there is a growing focus on patient safety interventions themselves, with some literature describing interventions qualitatively, but the majority of papers attempting to quantify the benefit to patient outcomes of certain interventions.

The Department of Health introduced the NRLS in 2004. The NRLS, designed to sit alongside local reporting systems, enables NHS staff in England and Wales to anonymously record patient safety incidents and near misses (when patient safety incidents were avoided). These reports are analysed to discover patterns in the data that may suggest measures to improve patient safety and prevent further patients being exposed to the same risk. Reporting across health-care sectors is variable; in 2009 EDs reported more than 600 serious/fatal events compared with only 14 reported by ambulance services in England (NPSA, personal communication); therefore, the extent of harm and risk in the ambulance service remains unknown. The reason for the disparity in reporting is unclear, but suggests failure to report, as there are indications that some systems within the ambulance service may be a threat to patient safety; for example, the lack of consistency in equipment, consumables and vehicle layout (NPSA).

Although some ambulance services are focusing on safety, < 50% of ambulance services and none of their related professional bodies signed up to the Patient Safety First campaign. Given that safety is a national priority, and there is an increase in litigation rates, it is unclear why ambulance services are not prioritising this issue. One reason may be that ambulance services are prioritising meeting targets;2 the culture in the ambulance service may not be conducive to disclosure of AEs. A further reason may be a lack of evidence of the impact of AEs within the ambulance service upon patient safety.

In order to explore the extent and quality of evidence available to ambulance services and to determine whether or not a systematic review and synthesis of the evidence on patient safety in pre-hospital care would be an important step in focusing attention on patient safety and guiding initiatives, a preliminary search of the evidence was undertaken.

Methods

We searched for all study designs and no language restrictions on patient safety in pre-hospital care in the MEDLINE database using the strategy detailed in Table 22. Additional studies were identified from the reference lists and experts on the team.

TABLE 22 - Preliminary search: Ovid MEDLINE® 1950 to June week 5 2010

#	Searches	Results
1	(pre hospital or pre-hospital or prehospital).mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]	6642
2	ambulance.mp. or exp Ambulances/	8018
3	emergency.mp. or exp Emergencies/	160,983
4	emergency medicine.mp. or exp Emergency Medicine/	10,926
5	paramedic.mp. or exp Allied Health Personnel/	37,185
6	emergency medical services.mp. or exp Emergency Medical Services/	74,593
7	emergency medical technicians.mp. or exp Emergency Medical Technicians/	4384
8	1 or 2 or 3 or 4 or 5 or 6 or 7	206,583
9	exp Safety/ed, lj, st, sn, td [Education, Legislation & Jurisprudence, Standards, Statistics & Numerical Data, Trends]	3270
10	8 and 9	201
11	limit 10 to humans	157

Results

Studies were selected by one reviewer (JDF) and were included if they reported data on any aspect of patient safety in the ambulance service. Studies focusing on vehicle accidents were excluded.

The search revealed 185 studies of which 24 were identified as relevant and included in the review (Figure 13). Excluded studies and the reasons for exclusion are listed in Table 23.

FIGURE 13.

Evidence selection process for the preliminary search of MEDLINE based on PRISMA.

TABLE 23 - Exclusions

CBRN, Chemical-Biological-Radiological-Nuclear; OR, odds ratio.

Study	Topic	Reason
Stymiest, 2003406	Major incident	Not relevant
Stoop, 2004407	Interagency major incident planning	Not relevant
Danielson, 1998408	Hazardous waste	Not relevant
McNamara, 1997409	Public and staff safety in ED using metal detectors	In ED
Thompson, 2003410	Fire safety in departments	Not relevant
Hawkins and National Flight Nurses Association, 2000411	Staff air safety of nurses	Not relevant
Bottle and Aylin, 2009412	Application of AHRQ to hospital data	Not relevant
Van De Velde et al., 2009413	Risk and safety of anaesthesia outside the operating room: NORA	Not relevant
Lundstrom et al., 2002414	Safety and culture	Not relevant
Rall and Dieckmann, 2005415	High reliability organisation principles to airway management: routine airway	Not relevant
Vaast and Puech, 2001416	Safety and transportation	Not relevant
Cosby and Croskerry, 2004417	Authority gradients in medicine	Not relevant
Anonymous, 2005418	Handling	Not relevant
Flannery, 2004419	Violence in health-care settings	Not relevant
McDaniel, 2005420	Disaster planning	In secondary care
McLaughlin, 2008421	Safety and air transportation	Not relevant
Cosby and Croskerry, 2003422	Teaching patient safety and in training and certification requirements	Not relevant
Valentin and International Commission on Radiation Protection, 2005423	High-dose-rate brachytherapy	Not relevant
Khan, 2004424	CBRN	Not relevant
Balonov and International Atomic Energy Agency, 2008425	CBRN	Not relevant
Cosby and Croskerry, 2004417	Authority gradient	Not relevant
Burkle and Hayden, 2001426	Co-ordination design	Not relevant
Anonymous, 2002427		Not relevant
Jessup, 2008428		Not relevant
Sudakin and Trevathan, 2003429	Safety regarding DEET	Not relevant
Osimitz and Grothaus, 1995430	Safety regarding DEET	Not relevant
Garcia, 2002431		Excluded: transport
Benson et al., 1994432	Air transport safety	Excluded: transport
Benson et al., 1994432	Flight following in-air medical transport	Excluded: transport
MacDonald, 2009433	Air medical transport	Excluded: transport
Wiwanitkit, 2010434	Transport nurse safety practice: requirement in developing countries	Excluded: transport
Shanaberger, 1993435		Excluded: transport
Zigmond, 2008436	Transport safety	Excluded: transport
Slattery and Silver, 2009437		Excluded: transport
McLaughlin, 2008421		Excluded: transport
MacDonald and Heffernan, 2002438		Excluded: transport
Jagim and Wylie, 1997439		Excluded: transport
Waller, 2002440	Safer vehicles, improved traffic records, more effective enforcement, enormously improved EMS	Excluded: transport
Simsic et al., 2008441	Safer vehicles	Excluded: transport
Nordberg, 2006442	Safer vehicles	Excluded: transport
Batchelor, 2009443	Safer vehicles	Excluded: transport
Erich, 2002444	Safer vehicles	Excluded: transport
Levick, 2008445	Safer vehicles	Excluded: transport
Lutz, 1987446	Safer vehicles	Excluded: transport
Amintabish, 1997447		Fire safety in health care
Barbey and Roose, 1998448	Mortality associated with SSRI overdose	Harm reduction/drugs
Kroesen, 1996449	Air safety crashes	Human error more frequent cause of helicopter accidents than technical failure
Errando and Blasco, 2006450	Medication errors	In critical care
Goupil, 1995451	Harm to patients and staff	In dental office
McCusker et al., 2009452	Discharge from ED	In ED
Sklar et al., 2010453		In ED
Hohenhaus, 2009454		In ED
Hicks et al., 2008455		In ED
Barata et al., 2007456	Medication errors	In ED
Brown, 2005457	Medication errors	In ED
Cadwell, 2008458	Medication errors	In ED
O’Neill et al., 2004459	Medication errors: misidentification	In ED
Ferns et al., 2005460	Staff safety	In ED
Nelstrop et al., 2006461	Restraint and seclusion as interventions	In ED
Schenkel, 2000462	Preventable AE	In ED
Campbell et al., 2007463	Error-producing conditions in ED	In ED
Chamberlain et al., 2004464	Safety in ED	In ED
Ciesielski and Clark, 2007465	Safety in ED-reducing delays and attendances	In ED
Manno, 2008466	Safety of neurological patient	In ED
Taylor, 2001467	Health-care safety net in the USA	In ED
Ternov and Akselsson, 2005468	Study of the causes of accidents leading to death in ED	In ED
Adams and Biros, 2001469		In ED
Anonymous, 2005470	Medication errors	In ED
Anonymous, 2009471	Medication errors, overcome those barriers	In ED
Cone and Davidson, 1997472		In ED
Friedland, 1991473		In ED
Anonymous, 2005474	Overcrowding	In ED
Anonymous, 2006475		In ED
Australasian College for Emergency Medicine, 2004476		In ED
Shaw et al., 2009477		In ED
McKinley, 2004478		In ED
Casteel et al., 2009479	Staff safety	In ED/mental health
Dixon-Woods, 2010480	Patient safety narrative review of four reports of ethnographic studies	In ED/OR
Griffin, 1995481	Equipment safety	In health care
Kennedy et al., 2009482	Medical trainees and asking for help	In hospital
Sebastian et al., 2004483	Surgery	In hospital
Leonidas, 2004484		In hospital
Singer et al., 2009485		In hospital
Oakley, 1997486		In hospital
Lucus, 2004487	Medication errors	In ICU
McCarthy and Gaucher, 2004488	Fire prevention	In OR
Farah et al., 1998489	Safety of delivering total body irradiation	In outpatient setting
Maggiore and Palmer, 2002490		In pre-hospital care
Takada, 2003491	Drug errors in chemotherapy	In secondary care
Benveniste et al., 2005492	Staff safety: assault	In secondary care
Brasic and Fogelman, 1999493	Staff safety: assault	In secondary care
Johnston et al., 2009494	Intraoperative MRI: safety	In secondary care
Mohammed et al., 2001495	Obstetrics and breech delivery	In secondary care
Moore, 2007496	Surgery: the safety net hospital model	In secondary care
Asplin, 2001497	Uninsured and underinsured residents in the USA	In secondary care
Bremner et al., 1999498	Overdose and mirtazapine	In secondary care
Cheng et al., 2004431	Coronary artery bypass graft surgery	In secondary care
Anonymous, 2005474	Overcrowding	In ED
Krug, 2008499		In ED
Scalise, 2003500	Six-sigma	In hospital
Weller et al., 2009501		In hospital
Goldmann and Kaushal 2002502	Medication errors	In hospital
Garnerin et al., 2007503	Data modelling for drug safety	In hospital
Stahel et al., 2010504		In hospital
Stahel and Mehler, 2009505		In hospital
Moldenhauer et al., 2009506	Resuscitation	In hospital
Lamont et al., 2010507	Oxygen safety	In hospital
Ma et al., 2007508		In ICU
Benjamin, 2003509		Medication errors
Marken and Pies, 2006510	Safety and tolerability of new drugs	Mental health
Basch et al., 2005511	Use of dietary supplements: adverse effects and interactions lead to increased emergency attendances	No data
Exadaktylos et al., 2005512	Providing flying doctor service	No safety
Ciarlet and Schodel, 2009513	Vaccine development: pentavalent rotavirus vaccine RotaTeq	Not pre-hospital
Novoa et al., 2009514	Road safety interventions in reducing road traffic collisions	Not pre-hospital
Wan et al., 2009515	Operating theatre safety	Not pre-hospital
Velianoff, 2002516	Overcrowding in ED	Not pre-hospital
Trzeciak and Rivers, 2003517	Overcrowding in ED	Not pre-hospital
Miller, 1994518	Hypertension and children	Not relevant
Wozniak et al., 2006519	Snake identification	Not relevant
Woudenberg and van der Torn, 1992520	Chemical exposure limits	Not relevant
Woolf, 2006521	AEs for herbs and dietary supplements	Not relevant
Welles et al., 2004522	Hazardous substance release	Not relevant
Van Tilburg, 1996523	Snowboarding safety	Not relevant
Isbister, 1990524	Therapeutic plasma exchange	Not relevant
Jaffe, 2008525	Effectiveness of paediatric rehabilitation	Not relevant
Kahn, 2004424	Biodefence	Not relevant
Kelly et al., 2005526	Schizophrenia and safety	Not relevant
Kleiman, 1997527	Platelet aggregation and coronary thrombosis	Not relevant
Kleindorfer et al., 2004528	Accident frequency and accident severity at covered facilities	Not relevant
Kopaladze, 2000529	Euthanasia of vertebrate animals	Not relevant
Lode, 2010530	Antimicrobial safety and RTI	Not relevant
Ta et al., 2006531	Fire safety interventions	Not relevant
Quail and Shannon, 2007532	Safety of pralidoxime	Not relevant
Pellatt, 2005533	Handling patients	Nurses
Read and Newell, 2005534		Obstetrics and gynaecology
Guise et al., 2008535		Obstetrics and gynaecology
Saizonou, 2006536		Obstetrics and gynaecology
Dart et al., 2005537	Sustained release paracetamol (acetaminophen) and overdose	Overdose
Novoa et al., 2009514	Prevention of RTCs	Prevention
Bratton, 1999538	Travel advice and primary care	Primary care
Conwit et al., 2005539	Safety and research	Safety and research
Jones, 1973540	Safety reviews in hospitals	Secondary care
Joseph and Hunyor, 2008541	The Royal North Shore Hospital inquiry	Secondary care
Pringle, 1991542	Safety and surgery	Secondary care
Tiguert et al., 2004543	Retropubic catheters and radical prostatectomy	Secondary care
Nadzam and Westergaard, 2008544		Secondary care
Sorra and Dyer, 2010545	AHRQ and hospital survey on patient safety culture	Secondary care: in hospital
Barer, 2008546	Landings	Space travel

The review revealed a small number of studies that explored safety in health care that focused on a number of broad topic areas: assessment and treatment,13,39,40,547,548–551 moving and transporting patients,552–558 patient/staff well-being,559 education228,286,560–562 and planning. 563–565 Of the eligible studies, 11 were reviews of the evidence39,547,548,549,552–554,566–568 (Table 24); however, no overall systematic review of the evidence for safety in pre-hospital care was found. Although no formal evaluation of the evidence was undertaken, the quality of the retrieved evidence varied markedly.

TABLE 24 - Reviews evaluating safety processes in pre-hospital care (n = 24)

Study and country	Topic	Indicative categories: patient safety, staff safety and well-being
Fitzpatrick and Duncan, 2009,39 UK	Repeat hypoglycaemic events	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
Timmermann, 2009,547 Germany	Airway management training	Patient safety: intervention(s) to improve patient safety
Dale et al., 2004,40 UK	Safety of telephone advice for patients requesting an ambulance	Patient safety: intervention(s) to improve patient safety
Barry, 2006,552 USA	HoverMatt system: transferring patients	Patient safety: intervention(s) to improve patient safety
Manser, 2009,566 Switzerland	Teamwork and patient safety	Patient safety: safety-related culture, attitudes and behaviour
Schneider et al., 1992,553 USA	Safety and transportation	Patient safety: intervention(s) to improve patient safety, also including staff safety
Tice, 2007,548 USA	Advanced directives as reportable medical errors	Patient safety: extent and nature of harm
Wilson, 2007,554 UK	Restraint of children in ambulance and thus safety of all occupants	Patient safety: intervention(s) to improve patient safety
Cox, 2002,555 USA	Air safety	Patient safety: intervention(s) to improve patient safety
Frakes and Kelly, 2007,560 USA	Adherence to safe practice recommendations	Patient safety: safety-related culture, attitudes and behaviour
O’Neil et al., 2009,556 USA	Safe transport of patients	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
Davis, 2010,561 USA	Medication errors	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
Hobgood et al., 2006,228 USA	Reporting errors: culture	Patient safety: safety-related culture, attitudes and behaviour
Hearns and Shirley, 2006,557 UK	Safety in retrieval	Patient safety: intervention(s) to improve patient safety
Faddy and Garlick, 2005,549 Australia	Pain relief	Patient safety: intervention(s) to improve patient safety
Limmer, 2000,563 USA	Emergency planning	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
McClincy, 1999,564 USA	Emergency planning	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
McLaughlin, 2007,565 USA	Emergency planning	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
Schwaab et al., 2005,550 Germany	Pre-hospital diagnosis of myocardial ischaemia by telecardiology	Patient safety: intervention(s) to improve patient safety
Burns et al., 1992,13 USA	The safety of patients receiving morphine sulphate in pre-hospital	Patient safety: intervention(s) to improve patient safety
Batchelder et al., 2009,286 UK	Teaching anaesthesia to doctor–paramedic teams using simulation	Patient safety: intervention(s) to improve patient safety
Oemrawsingh et al., 1989,551 Netherlands	Thrombolysis during ambulance transfer	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
Semonin-Holleran, 2008,562 USA	Orientation of equipment and resources for nurses accompanying patients	Patient safety: extent and nature of harm/intervention(s) to improve patient safety
Vidacovich, 2008,558 USA	Engineering and safety, comfort and communications in ambulances	Patient safety: extent and nature of harm/intervention(s) to improve patient safety

The literature formed two categories, one that explored issues related to patient safety and the other relating to staff safety and well-being. The eligible literature was mapped based on the above framework (Figure 14).

FIGURE 14.

Evidence framework for mapping ambulance service safety literature.

Discussion

The majority of these studies focus on aspects of patient safety, with fewer than one-third exploring safety issues related to staff. Overall, the studies were interventional with few exploring safety-related culture, attitudes and behaviour. There was a paucity of literature reporting methodological approaches to analysing patient and staff safety and well-being in ambulance services. No relevant methodological papers were found; two studies were identified that explored the application of tools designed by the AHRQ for patient safety but these reported data in other health-care sectors. 412,545

Conclusion

Overall, the review found a paucity of literature. It is clear that the evidence base on safety in ambulance services is lagging behind other health-care sectors, with patchy literature on patient safety interventions; thus, the extent of harm and risk is unknown. With no systematic review there is no evidence on which to base policy and direct future research.