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The aim of the study was to establish the opinions and perceptions of potential users of ambulance services as related to patient safety in ambulance services and the factors that have an impact on it. It was felt that useful insights might be gained from non-ambulance staff who had an understanding of how ambulance services function and are organised, and an awareness of some of the challenges faced by ambulance services.

Methods

In order to engage with members of the public and potential ambulance service users who had an understanding of how ambulance services operate, a meeting was arranged with the patient and public forum of a large metropolitan ambulance service. A short presentation relating to the purpose of the meeting and collection of data were provided, following which meeting attendees were asked to complete a questionnaire. Attendees were not obliged to participate and had the option of completing the

questionnaire anonymously.

The questionnaire comprised two sections, the first of which contained 49 questions and the respondent was asked to rate, using a 10-point Likert scale, how important they felt each issue was for ambulance services. A score of 1 rated the area as being of little concern with respect to patient safety, whereas a score of 10 rated the area as being of major concern with respect to patient safety. The questions were derived from work initially undertaken by the study team and the expert review group to develop a framework to categorise findings from the systematic literature review (seeChapter 3). This initial work analysed and compared the existing AHRQ conceptual framework, the London Protocol, the National Reporting and Learning Service framework, the Patient Safety First Safety Domains and the Yorkshire Contributory Factors Framework. All items identified from each of the frameworks were collated into a table and then each item was recorded on a card. Duplicate cards were removed. Each of the elements identified on the remaining cards was incorporated into section one of the patient and public

forum questionnaire.

The second section asked respondents to identify what they believed to be the five most important factors affecting patient safety in ambulance services (not in order of importance). Additionally, a free-text area was provided for respondents to add any additional information that they felt was important.

Results

Nine attendees of the patient and public forum meeting agreed to participate and completed

questionnaires. The scores for each participant on the ambulance service questionnaire were collated and analysed using IBM SPSS version 19.0. The mean scores for each element were calculated and are presented inTable 15; a higher score representing a perceived greater safety risk.

In section 2, attendees were also invited to identify what they perceived to be the five most important safety concerns (not in any particular order) and a free-text area was provided to allow attendees the freedom to raise any other issues they felt were important considerations that may not have been included within the questionnaire. There was considerable variation in these elements and it was not possible to

TABLE 15 The mean score for each element from the patient and public forum questionnaire (1 being of little concern and 10 being a major concern)

Dimension Element Mean score

Patient factors Patient language and communication 7.8

Personality and social factors 5.7

Patient factors, e.g. mobility 6.8

Patient condition or illness 8.3

Staff factors Education and training (level of) 8.2

Clinical knowledge (level of) 8.7

Clinical assessment skills (level of) 8.5

Critical thinking or clinical decision-making abilities (level of) 8.3

Active individual failure 8.0

Staff physical and mental health 7.4

Staff individual factors, e.g. personality/human factors 7.0

Safety knowledge 8.3

Team factors Supervision 8.0

Leadership and line management 8.1

Team structure (congruence, consistency, leadership, etc.) 7.8

Team communication 8.3

Work environment Care setting/physical environment/weather 6.5

Staffing levels and skills mix 8.4

Correct skills deployment 7.9

Operational efficiency 7.8

Shift patterns 8.7

Staff workload 8.4

Task and technology factors Communication systems (information technology) 7.9

Infection prevention and control 8.6

Decision-making aids 7.7

Availability and use of protocols/guidelines 8.1 Design, availability and maintenance of equipment 8.1 Availability and accuracy of test results 7.9

Vehicles 8.0

Organisational and management factors

Policies, standards and goals 7.0

Safety culture and priorities 8.3

Organisational culture 8.0

Implementation of care, review, monitoring 8.0 Documentation (records and identification) 7.6

Financial resources and constraints 7.2

summarise these data without losing a considerable number of viewpoints; however, it would not be unreasonable to draw the conclusion that the primary areas of concern relating to patient safety in ambulance services, from the perspective of participant feedback in the free-text section, could be broadly categorised as falling within the domains of clinical capability of individual ambulance clinicians and communication skills. Pressures placed on ambulance staff regarding workload were also identified as an area of concern by participants. Responses to section two are included inAppendix 9.

Discussion

There was a high level of consistency in responses to specific questions when comparing services that returned questionnaires. However, the overall ratings showed a degree of discrepancy when comparing services (one service had an average overall rating of 6.9 and another of 4.1). This suggested that different services applied the rating scales differently or they perceived different levels of risk to be associated with the different areas surveyed in the questionnaire. The most obvious area in which there were differences in ratings for different services was‘call handling triage/categorisation’(for which scores ranged from two to nine) and‘decision to leave at home’(for which scores ranged from two to nine). The observation that the most discrepant scores were associated with three services indicates differential experiences of these safety concerns. The additional ad hoc data given by participants of the prioritisation event were remarkably consistent with the main questionnaire findings.

There is considerable agreement among those involved in delivering ambulance services that operational delivery of services is key, with the highest safety risks cited by ambulance service medical directors being delays in gaining access to hospital and the patient handover process on reaching EDs. These findings indicate a pressing need for interorganisational research and the development of interventions spanning the link between ambulance services and emergency care.

TABLE 15 The mean score for each element from the patient and public forum questionnaire (1 being of little concern and 10 being a major concern) (continued)

Dimension Element Mean score

Institutional context factors Organisational performance (target mentality) 6.8

NHS executive 6.6

Consent, communication, confidentiality 7.4

Support from central functions 7.9

Links with external organisations 6.8

External policy 7.1

Economic and regulatory context 7.2

Outcomes Care pathways, including non-transport 8.0

Access, admission, transfer, discharge 7.2

Public involvement and expectation (end of life; destination alternatives)

7.1

Safeguarding 8.1

Medication errors 7.9

The patient forum exercise provides limited insight into the perceptions of the wider public with respect to what is important in terms of patient safety in ambulance services. Although the number of participants was low, it is apparent that perceptions of the patient and public forum are different from those of the ambulance service medical directors. Members of the patient and public forum had an excellent understanding of the issues facing ambulance services, yet their perceptions of what is important in relation to patient safety were not directly aligned with ambulance service perspectives. Those areas scoring a mean score greater than eight represented nine of the 25 topic areas from the literature review, namely assessment/management, communication, equipment/resources, individual factors, infection control, non-conveyance, safety culture, skill set and training.

Results of the patient and public forum exercise suggest that patients believe factors influencing the initial assessment undertaken by the responding ambulance clinician have the most significant impact on their safety, with operational issues being less important.

Care Quality Commission National Health Service staff survey data