An Integrative Systematic Review of Promoting Patient Safety Within Prehospital Emergency Medical Services by Paramedics: A Role Theory Perspective

Figures & data

Table 1 The Search Results

Databases From 2013–2023	Total Records of Each Database	Result of Title and Abstract Reading	Result of Full-Text Reading	Result of Quality Appraisal
PubMed (including Medline)	260	13	5	5
Scopus	666	11	4	4
Cinahl	445	4	1	1
ProQuest	498	10	2	2
Web of Science	96	0	0	0
Embase	432	19	4	4
Total of databases	2397	57	16	16
Duplications	635	–	–	–
Manual search/backtracking references	0	6	0	0

Figure 1 The search process.

Table 2 The Characteristics of the Studies Selected for Research Synthesis in This Systematic Review

Author, y	Country	Design/Focus	Sample and Setting	Data Collection and Analysis	Outcome Measurement	Implication for Patient Safety
Burrell et al, 2013^Citation29	UK	Qualitative/Decision-making process of ambulance clinicians in epilepsy as the neurological condition	15 ambulance Clinicians in south of London	Individual interviews, qualitative content analysis	Triage and assessment of patients with epilepsy	Need for robust training and guidelines for making decisions regarding the conveyance of patients with epilepsy
Ho et al, 2014^Citation35	USA	Prospective, blinded observation/Hand-sanitization by EMS staff	53 EMS providers during 258 patient contacts in an urban area	Prospective blinded observation during work shifts using a checklist	Hand-sanitization event	Need for improving precautionary hygiene practices, education, and provision of hand-hygiene equipment
Vicente et al, 2014^Citation27	Sweden	Randomized controlled trial/ Transporting older adults directly to community or hospital by ambulance nurses	410 people in the intervention and 396 in the control in a suburban area	Number of individuals triaged to community, subsequent transferals to emergency department; inferential and descriptive statistics	Decision making by the ambulance nurse with the help of the prehospital decision support system	Optimizing resources and improving emergency care of older people
O’Hara et al, 2015^Citation30	UK	Qualitative/Decision making by paramedics for care transitions	n=21, n= 57, n=10; 3 ambulance service trusts	Document review, focus group interviews (n=21), observing 57 staff across 34 work shifts, digital diaries (n=10); qualitative analysis	Key influences on transition decisions and potential risk factors	Skilled workforce to manage diverse patient needs, reduction of emergency department conveyance, access to patient care options as alternatives to emergency departments
Barr et al, 2017^Citation23	Australia	Survey and qualitative/Self-reported behaviors and perceptions of hand hygiene and gloving practices	n=417, n=12 paramedics	Questionnaire survey, focus group interviews/thematic analysis	Acceptance and compliance with practice	Need for substantial improvement to reduce the risk of infection transmission
Reuter and Camba, 2017^Citation31	USA	Qualitative and survey/Perspectives about health, safety, the work environment, and gaps in well-being	Five EMS groups, n=4, n=12, n= 103 within central and eastern Texas	Multi-phase, mixed methods: performance and experiences during individual task conditions, participants’ shadowing observation, individual interviews, survey	Safety issues and current efforts to address them	System approach, eliminating redundancy or ill-cooperating equipment, efficient ergonomic solutions for EMS environments to be aligned with the workflow
Rosen et al, 2017^Citation32	USA	Qualitative/Attitudes and self-reported practices of EMS providers surrounding identification and reporting of elder mistreatment	27 EMS providers, a single large, private, hospital-based ambulance service	Focus group interviews, qualitative content analysis	Elder mistreatment	The need for empowering EMS providers through training, communication, documentation, and feedback mechanism
Sinclair et al, 2018^Citation36	Canada	Survey and qualitative/Self-reporting of patient safety incidents	1153 paramedics in an Ontario region	Clinical scenarios, open-ended questions, survey and qualitative analysis	Barriers to self-reporting	Culture change to facilitate identifying patient safety threats
Hagiwara et al, 2019^Citation37	Sweden	Retrospective survey/Incidence of adverse events prehospital care and factors contributing to them	30 prehospital medical records	Prehospital medical records, retrospective study	Actions or inactions by EMS staff	Prevention of deviations from care standards and incomplete documentation
Backman et al, 2019^Citation28	Sweden	Qualitative/Nurse’s decision making about patient’s need for ambulance care	8 ambulance nurses, an ambulance station in northern central Sweden	Individual interview, content analysis	Differences in ambulance nurses’ perception and patient’s and relatives’ perceptions of the need for ambulance care	Improved cooperation between different levels of care, need for experience, knowledge and dedication
Bury et al, 2019^Citation24	Ireland	Survey/Knowledge, understanding about the implications and possible effects of an act in which a patient with capacity may validly refuse treatment in an emergency	85 graduates of advanced paramedics	Experience and awareness questionnaire, case scenarios, online survey	End-of-life and deliberate self-harm situations potentially requiring resuscitation	Changes in medical education, professional practice, and clinician-patient interactions
Larouche et al, 2019^Citation38	Canada	Observation/Factors that may favor or inhibit the application of safe handling principles by paramedics performing full-body transfers of patients from a stair chair to a stretcher	45 patient transfers involving 35 different teams of paramedics	Observation, semi-structured interviews, observational field study and qualitative study	Safe handling principles	Training not by focusing on handling techniques but by focusing on compromise and the capacity to adapt work techniques based on the working context and the team-mate
Stander et al, 2021^Citation33	South Africa	Qualitative/Responsibilities toward management of mental healthcare users and the community during behavioral emergencies	19 prehospital emergency care providers	Focus group interviews, grounded theory	Moral and medical responsibilities	Revision of legislation, better education, skill development and awareness of mental healthcare
Munjal et al, 2022^Citation26	USA	Pilot intervention/Mitigating risks of care transitions to patient home through the transport PLUS intervention by EMS technicians	103 EMS technicians and 439 patient encounters	Fall safety assessment, discharge comprehensive assessment, pilot intervention	Acceptance of the Transport PLUS intervention by patients and accuracy of assessment by emergency technicians, 3-day and 30-day readmission or revisit	Preventative community paramedicine and patient acceptance
Thorvaldsen et al, 2022^Citation25	Norway	Survey/Use of blankets, bandages, and Velcro straps to restrain patients in transit	400 ambulance service staff in a county	Questionnaire of applied coercion online survey	Use of coercion	Discussion about how ambulance services can be provided in a safe, secure, and caring way
Vahakangas et al, 2023^Citation34	Finland	Qualitative/Paramedics’ experiences of working in prehospital emergency care, regarding urgent hospital transfers and related skills	20 paramedics, discussion group on the Facebook	Individual interview, content analysis	Safe urgent hospital transfers	Organizational support, professional competence, interprofessional skills, standardized procedures

Abbreviation: EMS, Emergency medical services.

Figure 2 Factors influencing the roles of paramedics in patient safety in relation to the domains of the role theory.

Burrell L, Noble A, Ridsdale L. Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study. Emerg Med J. 2013;30(3):236–240. doi:10.1136/emermed-2011-200388

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Ho JD, Ansari RK, Page D. Hand sanitization rates in an urban emergency medical services system. J Emerg Med. 2014;47(2):163–168. doi:10.1016/j.jemermed.2013.08.070

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O’Hara R, Johnson M, Siriwardena AN, et al. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. J Health Serv Res Policy. 2015;20(1 Suppl):45–53. doi:10.1177/1355819614558472

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Barr N, Holmes M, Roiko A, Dunn P, Lord B. Self-reported behaviors and perceptions of Australian paramedics in relation to hand hygiene and gloving practices in paramedic-led health care. Am J Infect Control. 2017;45(7):771–778. doi:10.1016/j.ajic.2017.02.020

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Rosen T, Lien C, Stern ME, et al. Emergency medical services perspectives on identifying and reporting victims of elder abuse, neglect, and self-neglect. J Emerg Med. 2017;53(4):573–582. doi:10.1016/j.jemermed.2017.04.021

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Sinclair JE, Austin MA, Bourque C, et al. Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. Prehosp Emerg Care. 2018;22(6):762–772. doi:10.1080/10903127.2018.1469703

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Hagiwara MA, Magnusson C, Herlitz J, et al. Adverse events in prehospital emergency care: a trigger tool study. BMC Emerg Med. 2019;19(1):14. doi:10.1186/s12873-019-0228-3

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Backman T, Juuso P, Borg R, Engström Å. Ambulance nurses’ experiences of deciding a patient does not require ambulance care. Nurs Open. 2019;6(3):783–789. doi:10.1002/nop2.255

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Bury G, Thompson A, Tobin H, Egan M. Ireland’s assisted decision making capacity act-The potential for unintended effects in critical emergencies: a cross-sectional study of advanced paramedic decision making. Ir J Med Sci. 2019;188(4):1143–1148. doi:10.1007/s11845-019-01994-w

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Stander C, Hodkinson P, Dippenaar E. Prehospital care providers’ understanding of responsibilities during a behavioural emergency. S Afr J Psychiatr. 2021;27:1545. doi:10.4102/sajpsychiatry.v27i0.1545

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Munjal KG, Yeturu SK, Chapin HH, et al. Feasibility of the transport PLUS intervention to improve the transitions of care for patients transported home by ambulance: a non-randomized pilot study. Pilot Feasibility Stud. 2022;8(1):169. doi:10.1186/s40814-022-01138-5

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Thorvaldsen N, Bergem AK, Holst Ø, Häikiö K. Coercion in the ambulance setting. Tidsskr nor Laegeforen. 2022;142(14). doi:10.4045/tidsskr.22.0086

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Vähäkangas P, Nordquist H, Terkamo-Moisio A. Urgent hospital transfers - The experiences and required skills of paramedics. Int Emerg Nurs. 2023;67:101269. doi:10.1016/j.ienj.2023.101269

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