The clinical role of ambulance services 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.

Adverse events and ambulance care: high costs

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, with 50% of such events potentially having been preventable had lessons been learnt from previous incidents.

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 System and An Organisation with a Memory 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.

Results of the research

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, 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.

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.

Patient safety: a growing focus across all health-care sectors

A recent PhD thesis 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 the 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, 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.