Introduction

Prehospital Emergency Medical Services (EMS) known as ambulance services or paramedic services has been defined as an

Integrated system of medical response that includes the full spectrum of response from recognition of the emergency to access of the healthcare system, dispatch of appropriate response, pre-arrival instructions, direct patient care by trained personnel, and appropriate transport or disposition.1

Patients choose to utilize EMS because of limited access to primary care and perception of their condition’s urgency influenced by the opinions of families, friends, or other healthcare professionals as they believe that EMS offers necessary resources and facilities for their condition.2 Also, worried family caregivers frequently reach out to EMS for immediate assistance when they observe concerning and unforeseen signs of disease progression or approaching death. This action establishes paramedics as the initial point of contact for care.3

Paramedic education and training varies globally, encompassing differences in curriculum, length of training, and entry requirements. Disparities extend to training programs’ content, equipment utilization, and intensity. They cause variations in paramedic roles, impacting autonomy, authorized procedures, and collaborations with healthcare professionals. In general, paramedic education and training have traditionally focused on emergency medicine, with less focus on primary care and public health. In developed countries, paramedic roles are evolving due to factors like aging populations, increased chronic conditions, technological advancements, changing community expectations, and broader healthcare system challenges. Countries like the UK, Australia, and New Zealand are moving toward almost mandatory higher education for paramedics, typically through three-year bachelor’s degree programs. These degrees offer the flexibility to incorporate a broader range of studies in primary care and public health. However, in countries without widespread access to bachelor’s degrees in paramedicine, expanding paramedic education within the constraints of short entry-level programs seems nearly impossible.4 Transformations in ambulance services in the UK have caused transitions in the education of paramedics from in-house, apprenticeship-style training lasting several weeks to an academic model, now offered through university-based undergraduate programs.5 While diverse program variations intend to equip community paramedics for addressing a wide spectrum of population health and social needs, the training itself lacks clear description. This highlights the urgent need for the establishment of formalized training or education frameworks.6 Accordingly, initiatives seek to standardize and enhance paramedic education, training, and responsibilities for consistent, high-quality emergency care internationally.

Over the past few decades, the role of paramedics has undergone a substantial evolution,7 as they have been granted the authority to deliver crucial life-saving interventions, particularly with the access to advanced equipment and treatment options.8 The profile of paramedics encompasses roles such as clinician, health and social advocate, team member, educator, professional, and reflective practitioner. Additionally, the overarching theme of patient safety as the prevention, reduction, and mitigation of harm or potential harm to patients during the provision of healthcare is a core aspect present in all these roles.9

Various factors can impact patient safety, potentially leading to adverse events or near misses in the EMS context. These factors encompass systemic elements such as workplace culture, institutional policies, procedures, protocols, staff training, technological and engineering solutions, and ergonomic considerations. Also, human factors such as complacency, fatigue, task allocation, communication, judgment, and decision-making play critical roles in patient safety.10

The quality and safety of EMS has significantly improved in recent years, reflecting a heightened awareness of past safety issues and effective measures taken to address them.11 Current patient safety recommendations in EMS encompass raising awareness regarding the principles of patient safety and adaptation of safety strategies from other healthcare disciplines.12 Nevertheless, disparities in attitudes, roles, and responsibilities concerning patient safety within EMS result in cognitive dissonance among paramedics.13,14

In the realm of prehospital care, a singular method for measuring and monitoring patient safety is unavailable. Monitoring systems have developed over time,15 but there is still the need to prioritize the integration of patient safety principles within EMS16 underpinned by studying and examining roles in ensuring a common approach to patient and staff safety.

Acknowledging the lack of integrated knowledge and understanding of how paramedics uphold patient safety in their practice, the aim of this review was to enhance our knowledge and assess the various aspects of their roles, from initial patient assessment to transport and handover, focusing on the measures and interventions implemented to ensure patient safety within the context of EMS. Therefore, our review question was: What roles paramedics have in the preservation of patient safety and prevention of errors and what are the requirements for playing those roles?

Materials and Methods Design

A systematic review with an integrative approach was conducted. This methodological approach offers a comprehensive and rigorous means of synthesizing existing knowledge, thereby addressing complex questions and issues across various fields of healthcare. By integrating diverse sources of evidence, such as quantitative and qualitative data, the integrative approach ensures a more holistic understanding of a given topic, allowing for a multifaceted analysis.17 Integrative review synthesis is invaluable for both researchers and policymakers and contributes to the advancement of knowledge and practice. Following Whittemore and Knafl’s (2005) framework,17 this review adhered to a five-step process: identifying the research problem; conducting a comprehensive literature search; evaluating data, which involved assessing quality; performing data analysis and synthesis using a narrative approach; and presenting the findings.

Protocol and Registration

To enhance transparency, ensure the integrity of the review process, and reduce the risk of publication bias, the review protocol in terms of review’s objectives, methods, and analysis plan was registered under the PROSPERO ID: CRD42023435026.

The review protocol was created collaboratively by a diverse, multinational team, with each member contributing their expertise in study design, data analysis, and review topic, resulting in a dynamic and finalized protocol.

The review’s objectives and approach were formulated using the PICo framework, as outlined below: P (Population): Paramedics with the educational degrees of associate, bachelor, and master involved in EMS; I (Interest): Roles as practical considerations, interventions and strategies in the context of patient safety culture as the prevention, reduction, and mitigation of harm or potential harm to patients during the provision of healthcare; Co (Context): EMS as emergency situations before a patient reaches a hospital or medical facility and during emergency transfer to hospital or between hospitals in the multi-disciplinary care context.

Search Process

The review was prompted by a noticeable absence of an integrated understanding of how paramedics contributed to patient safety, serving as a compelling reason for conducting this investigation. A team of researchers from Norway, Estonia, and Spain, each possessing specialized knowledge in patient safety, paramedics, EMS, and systematic review methodology, was assembled. Following the development of the review protocol, an extensive and all-encompassing search of the literature was conducted on various databases, including PubMed (which comprises MEDLINE), Scopus, Cinahl, ProQuest, Web of Science, and EMBASE, with the aim of retrieving studies published in the past decade, covering the period from 01 Jan 2013 to 30 Sep 2023.

To perform the search, search strings were formulated by translating Medical Subject Headings (MeSH) and thesaurus entry terms into terms compatible with all selected databases. Search queries were built using Boolean logic and truncation, including operators like AND/OR. Additionally, an initial search was conducted on the Google Scholar to identify relevant keywords associated with the review topic, drawing on personal research experiences. The expertise of a librarian was enlisted to provide guidance and consultation to ensure the accuracy of the overall search process. Various versions of key terms related to paramedics, EMS, and patient safety were employed (Supplementary File 1).

Furthermore, a manual exploration was performed in respected journals publishing articles on the review topic. Cross-references from the bibliographies of retrieved articles and current review papers were also performed for improving the search coverage. The gray literature encompassed contemporary profiles detailing paramedics’ roles in EMS in the context of patient safety, which were retrievable through a Google search.

Selection of Studies

Inclusion and exclusion criteria: All original research studies employing qualitative, quantitative, and mixed-methods designs were considered for inclusion. Original and scientifically rigorous content were selected using the following criteria: studies focused on the review subject; in the context of EMS; paramedics; published in peer-review scientific journals in English. Reviews, commentaries, letters, case reports, case studies, conference proceedings, and books were excluded. Additional studies focusing on pediatrics, child and neonatal care, investigations involving the participation of non-paramedic staff within EMS such as doctors and published prior to 2013 were excluded.

Screening: The results of the search were uploaded to the Rayyan online platform for systematic reviews. The systematic screening and selection of studies were carried out independently by two review authors (MV, MS) possessing expertise in systematic reviews, paramedics, and patient safety, in accordance with the eligibility criteria applied to the articles’ titles, abstracts, and full texts. Subsequently, the review authors shared their findings and engaged in discussions to decide on the review next steps. They addressed disparities and reach a consensus. Additionally, in cases of disagreements, the perspectives of other review authors (MFVM, KI, JS, LL) were sought.

Quality Appraisal and Risk of Bias Assessment

It encompassed a thorough assessment of credibility, pertinence, and findings conveyed in the selected studies. The JBI Critical Appraisal Tools18 customized to suit the specific research methodologies of the studies including cross-sectional, cohort, quasi-experimental, and qualitative were used. Additionally, for cohort and quasi-experimental studies, the Risk Of Bias In Non-randomized Studies – of Interventions (ROBINS-I) assessment tool19 was also used.

Each author independently evaluated the studies using the checklist and furnished comprehensive explanations of his/her perspective on the studies’ quality. A joint determination regarding whether to include or exclude studies in the research synthesis was made. This decision-making process entailed considering the importance, methodological quality, and potential bias, ensuring a rigorous and well-informed selection process.

Data Extraction and Research Synthesis

To gather and bring in data from the selected studies, an extraction table served as a tool for arranging, summarizing, and comparing the study results. Substantial variations in research methods, objectives, and outcomes across the selected studies hindered conducting a meta-analysis. Therefore, the review findings were presented in a narrative format.

To conceptualize the roles of paramedics in ensuring patient safety, the review findings were reflected to and analyzed through the role theory.20 This theory helped identify how individuals perceived their roles, understood their functions, and recognize factors that either facilitate or hinder effective role performance.

Conway’s Role Theory is a sociological framework about individuals’ engagement in executing specific roles and how their roles influence their attitudes and behaviors. This framework can inform policymakers about the scope of practice for staff and guide decisions regarding education, training, licensure, and adaptation to new roles and expectations. Five categories for role constructs delineated within this theory21,22 are as follows:

Role ambiguity: Uncertainties and disagreements about role expectations cause confusion and miscommunication leading to neglecting important tasks. Role conflict: Conflicting or incompatible role expectations when responding to various patient needs hinder fulfilling tasks. Role overload: Insufficient resources to meet potentially overwhelming demands result in challenges in the provision of adequate attention and care. Role identity: Understanding and internalizing role expectations, establishing norms for attitudes, behaviors, and thoughts are required for playing roles. Role insufficiency: Barriers to fulfilling role expectations and obligations associated with roles cause the feeling of inability to play the role.

This integrative systematic review adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement for its development and reporting (Supplementary File 2).

Ethical Considerations

Ethical approval was not required for this review study as it did not involve the inclusion of human samples.

Results Search Outcome and Selection of Studies

The initial database search resulted in 2397 studies (see Table 1). After removing duplicate studies and excluding those deemed irrelevant to patient safety or those discussing the roles of healthcare staff other than paramedics within the context of EMS, as well as the screening of articles based on their titles and abstracts, and full-text appraisals, a final selection of 16 studies for data analysis and research synthesis was reached. For a visual representation of the search process, refer to Figure 1, which aligns with the PRISMA guideline.

Table 1 The Search Results

Figure 1 The search process.

Quality Appraisal

For cross-sectional studies,23–25 they appropriately provided descriptions of the criteria for sampling and recruitment, as well as the exposure and its measurement.

Experimental studies as a pilot intervention26 and a clinical trial27 indicated the presence of a causal relationship between variables, methods of sampling and group assignment, follow-up procedures, and measurement of outcomes.

For qualitative studies,28–34 the appropriateness of the research design, transparency in data collection and analysis, ethical considerations, and the credibility of the study findings were evident.

Regarding assessment for bias in the clinical trial study,27 there was a minimal to moderate likelihood of bias in various factors, such as confounding, participant selection, intervention, data, measurement, and result reporting, across the selected studies.

As a result, all selected studies were deemed to have sufficient quality for inclusion in the data analysis and research synthesis.

General Characteristics of the Selected Studies

They were published in English, covering the period from 2013 to 2023. A summary of the chosen studies, encompassing information about the country, research objective, method, sample and setting, outcomes, key findings, and implications for patient safety, has been presented in Table 2.

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

Paramedics Role in Patient Safety

The review findings were reflected to the domains of role theory, as outlined in Figure 2. Specific examples from the studies were provided narratively within each domain for illustration.

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

Role Ambiguity

It was about the lack of adequate knowledge and skills, as well as guidelines and protocols, which contributed to role uncertainties and ambiguities among paramedics.

One notable example was the identification of risks for elder abuse during home visits by paramedics. However, there were no specific EMS protocols or training in place for reporting such cases.32

Paramedics often felt confused and lacked confidence when dealing with patients experiencing complex partial seizures due to inadequate training and patient management guidelines. As a result, they had to rely on their clinical experiences to make decisions regarding the patient transport.29

The algorithm for managing mental healthcare patients and obtaining their consent for care was deemed overly vague and simplistic, underscoring the necessity for a comprehensive improvement.33 While hand hygiene and gloving were recognized as important practices, poor compliance with these measures was linked to insufficient competency-based training, particularly in understanding the potential transmission of infectious diseases.23

Paramedics reported the need for unbuckling themselves within the ambulance for procedures such as cardiopulmonary resuscitations, intubation, inserting intravenous lines, restraining patients, retrieving supplies, and repositioning patients. This was seen as going against current practice protocols, which could potentially jeopardize their own and patient safety.31

Additionally, paramedic staff encountered challenges with emergency authorities who were unresponsive to their concerns related to patient care and failed to follow up on their reports.32 An unclear scope of responsibilities in handling aggressive patients and transporting involuntary patients exacerbated their role ambiguities.33

These role ambiguities were linked to paramedic staff experiencing feelings of anxiety and vulnerability when making decisions about whether to discharge patients on the scene or transport them to ensure patient safety.29,32,33

Role Conflict

It stemmed from overlapping roles between paramedics and other healthcare professionals, challenges in collaboration with other clinicians, and difficulties involving patients and their families at the emergency scene.

One of the challenges in communication within the multidisciplinary team was the difficulty in interacting with social workers, which revolved around reporting observations of elder abuse during follow-up home visits perceived as being beyond the typical scope of paramedics’ duties.32 Paramedics held the belief that addressing mental illness fell outside of their scope of practice, as they did not consider it in their role to enforce mental healthcare. Instead, they emphasized the responsibility to report their observations on the scene to the receiving facility, ensuring that patients received appropriate care.33

On the other hand, having a colleague to rely on as a source of support in situations where there was uncertainty about the necessity for ambulance care for a patient created a sense of security.28 Miscommunication among paramedics was identified as a source of conflict. This was particularly concerning when inexperienced staff did not fully comprehend the complexities of working in an ambulance. For instance, errors in conveying medication instructions from inexperienced staff had serious consequences, but qualified staff handled urgent hospital transfers professionally and competently.34

Skills in cooperation, communication, active listening, and the ability to access written information from the patient’s journal before or during the patient encounter were imperative for paramedics to report and receive critical information leading to the expedition of emergency operations and prevention of adverse events.28,34 However, to mitigate conflicts between paramedics and healthcare providers in emergency departments, what was lacking were mutual respect and collegiality, along with shared learning from incidents. They could foster better collaboration and understanding between them.36

Challenging and conflicting situations arose when patients and their families insisted on ambulance care, even when it was deemed unnecessary by paramedics. They faced a dilemma while attempting to explain, in a language the patients and their relatives could understand, why ambulance care was not needed. This sometimes led to misunderstandings and tensions despite paramedics’ good intentions.28

Paramedics experienced pressure to play their roles when in a public setting where bystanders expected them to administer medications to the patient. When patients actively participated in the decision-making process regarding transfer to the hospital, it bolstered the confidence of paramedics in making transport decisions.29,33

Role Overload

It was related to the EMS environment, availability of facilities and equipment, and work demands.

Paramedics raised concerns about the inadequacy of facilities to create a safe environment for patients’ recovery, which would enable further investigation and treatment without the immediate need for transfer to emergency departments.29 In certain situations, barriers to accessing appropriate alternative care options, particularly in rural areas, forced them to transport patients even when it might not have been the most efficient choice.30

Inadequate organizational support for making clinical decisions for patients with epilepsy to avoid unnecessary transfers and mitigate liability added to their workload and work burden.29 Paramedics experienced the heightened feelings of surprise, accomplishment, and uncertainty when they were tasked with transporting an emergency patient without the immediate presence of an attending physician.34

The increased demand for ambulance services had a notable impact on the clinical decision-making process. Paramedics should have made decisions concerning a broader spectrum of primary care and psychosocial emergency cases. These cases were complex and time-consuming, necessitating a high level of skill and support to minimize the potential for errors, particularly in time-critical emergencies where response time targets, on-scene time, and conveyance rates were crucial.30

Paramedics experienced a sense of being out of control of the situation when they had to wait for additional help to arrive. This delay in getting patients en-route to the hospital quickly added to their time constraints. It required a significant mental effort to efficiently organize patient care once the necessary support arrived.31

They also faced pressure due to the tension between service demands and the availability of resources. Disparities in access to specialist paramedics, vehicles, their proximity to where they were needed, availability of equipment and medications, as well as training on their usage, had the potential to influence decisions regarding patient care and occasionally resulted in adverse events. In some cases, the absence of basic equipment in vehicles hindered time-saving efforts during emergency situations.30,31,34,37 Several barriers to practicing hand hygiene during clinical cases were identified. These included a lack of access to suitable hand hygiene facilities with running water, limited availability of hand hygiene products, insufficient resources for drying hands before donning gloves, and potential skin reactions to alcohol-based products.23

Stress and perceived work demands were also associated with equipment that functioned improperly and constraints related to time and organization.31,38 Paramedics viewed their job as time-consuming and emotionally and physically demanding. A range of emotions, including fear, frustration, apprehension, anger, and uncertainty were experienced when dispatched to emergencies involving mental health patients, as well as older and fragile patients being at risk of self-harm or harming others. The urgency of such situations left them with limited time for careful analysis and decision-making.31,33,38 Pressure also increased when patients declined care, especially when paramedics were concerned about the risk of patient injury or even death.24

Role Identity

It indicated attitudes, behaviors, and cognitions that were necessary for fulfilling the role of a paramedic. They influenced adherence to protocols and guidelines, concentration on patient safety, having the sense of moral and caring responsibility, efforts to acquire knowledge and skills, and maintaining collegial relationships with other healthcare professionals.

Paramedics demonstrated their capability to adopt protocols and guidelines, particularly in the context of identifying potential elder mistreatment and fall hazards during home visits. They assisted other healthcare providers in elder protection.26,32

They employed checklists and information transfer routines when interacting with different emergency departments,34 followed guidelines and flowcharts, and felt possessing the ability to make a rapid clinical assessment at the first glance, which instilled the sense of confidence in their abilities.28 Consequently, they adopted safe techniques for patient transfers including adjusting equipment height to make use of gravity when moving a patient to a lower surface, ensuring a clear and properly positioned workspace before the transfer, and utilizing available equipment such as boards or sheets to reduce friction and facilitate sliding between the patient and surfaces.38

Paramedics placed a strong emphasis on their moral and medical responsibilities toward patients,33 and aimed at striking a balance between patient safety and patient choice when making decisions about whether transport the patient.29,33 They expressed a strong intention to self-report adverse events and near misses affecting patient safety.36

They consistently acted in the patient’s best interests and took steps to prevent further harm, promote health, and persuaded patients to agree to transportation, thereby saving them from the lengthy waiting times in the emergency room and helping arrange alternative care when needed.28,33 They gained patients’ trust by providing clear information about their assessment and ensuring them to feel calm and safe before leaving them at the scene.28

Paramedic staff possessed knowledge of a variety of treatment methods to respond promptly to a patient’s condition, particularly when dealing with patients who had unstable health conditions during the transfer process.34

They were capable of performing interventions, such as terminating a seizure, in accordance with the training they had received.29 For urgent hospital transfers, paramedics recognized the need for intensive care competences, pharmacological expertise, situational driving skills, understanding the vehicle’s technology, proficiency in map reading, and expertise in handling equipment. These competences contributed to creating a calm atmosphere during transfer ultimately improving patient safety.34

Direct patient care was carried out after performing hand sanitizing and hand hygiene, especially in case of direct patient care and handover. It was crucial for protecting both paramedics and patients from spreading infections.23,35

Maintaining up-to-date competence, especially for situations encountered infrequently, was emphasized.30 Paramedics valued the ability to recognize and understand their own limitations and seek assistance when necessary, during patient transfer. Qualities such as humility, initiative, and strong problem-solving skills were considered essential in their role.34 The importance of utilizing standardized decision support tools and algorithms to avoid the inappropriate use of emergency departments and to optimize patient transfer was emphasized.27,30

Paramedics found that communication and sharing experiences with their colleagues enhanced their overall sense of safety.28 In challenging situations or when facing difficult decisions, they engaged in consultations with informal peer networks and sought advice from colleagues and the patient’s general practitioner.30

They emphasized the importance of receiving timely, educational, and constructive feedback after self-reporting incidents.36 An easy access to support for handling complex situations as a vital aspect of their professional development and well-being was highlighted.24,32

Role Insufficiency

Barriers to training and practice alignment, coordination, effective dispatch system, and organizational support were reported by paramedics.

A mismatch between the training received by paramedics and the practical expectations of their role was identified. It encompassed the lack of adequate guidance for managing non-medical emergencies highlighting the need for more comprehensive education beyond medical-oriented training.29,33 Insufficient training on urgent hospital transfers and absence of collaborative exercises involving the multidisciplinary emergency team was also mentioned.34 As a result, limitations in training, professional development, and skill-building impeded the competence and confidence of paramedics when it came to making complex decisions regarding patient transfer.30 When existing guidelines restricted their capacity to assist patients, such as preventing them from administering medications, or if they encountered challenges in being dispatched to patients in alignment with their specialties, their sense of insecurity and frustration was heightened.28–30,34

In situations involving multiple patients managed by several teams, achieving effective coordination and timely organization was often challenging.31 The absence of cooperation from the police when it came to transferring patients who did not consent for being transferred was a significant challenge.33

Paramedics encountered challenges with the dispatching system, which at times provided inaccurate information about the type of emergency they should be prepared to handle.33 Paramedics frequently received limited and misleading information when dispatched to calls. Accessing and staying updated with information communicated through multiple channels proved to be challenging.30 Also, the pressure to complete each clinical case within a short turnaround time hindered effective hand hygiene practices and reduced compliance to standards.23 Additionally, non-conveyance decisions with the aim of reducing admissions to emergency departments were frustrating. The absence of access to alternative services or community resources often necessitated patient conveyance to the hospital.30

Discrepancy in messages received from the organizational management and quality of paramedic services affected decisions regarding how to enhance the performance and capabilities of paramedics.36 Following the implementation of the new act that granted patients the authority to refuse treatment and the enforcement of assessing patients’ living spaces, paramedics expressed concerns about how to handle interventions and were uncertain about the appropriate course of action.24,26

Challenges including the fear of legal repercussions in case of complications, pressure of meeting public expectations, limited on-scene access to patient information, and need for alternative care pathways instead of immediate transportation hindered their ability to carry out their duties effectively.29 Paramedics were deterred from reporting incidents due to the fear of being suspected, terminated, or punished. Low confidence in organizational support in the event of an incident was due to the focus on assigning blame rather than promoting learning.30,36 The absence of constructive feedback on clinical decisions limited opportunities for paramedics to reflect and learn from incidents.30

Adverse events frequently occurred because of deviations from the standards of care, such as performing interventions or administering medications that seemed to fall outside protocol, or failing to carry out interventions or provide medications that were within the standard of care. Additionally, incomplete, or unclear documentation contributed to adverse events.37 For instance, paramedics resorted to coercion and not using a fastened seatbelt to ensure patient safety when patients were in transit.25 Positioning around the patient and equipment, having the stretcher at a height equal to or higher than the stair chair, transferring the patient onto the stretcher, lifting the patient, adjusting the final height of the stretcher, repositioning the patient on the stretcher, and pulling up the patient’s entire body were some examples of deviations from standard procedures.38

Discussion

The objective of this review was to comprehend the role of paramedics in promoting patient safety within EMS, which was aligned with the role theory to identify factors that facilitated or impeded role performance.

Inadequate knowledge and skills, along with inappropriate guidelines and protocols for carrying out assigned tasks, posed barriers to paramedics in their efforts to maintain patient safety. While there is advocacy for the implementation of the role of paramedics, there is a lack of comprehensive information about the clinical contributions and responsibilities of paramedics in this context.39 Paramedicine training programs should enable them to address a wide range of health and social needs related to identifying risks for hospitalization and readmissions, as well as home visits, medication management, and referrals to community services.6,40 Ambulance personnel express a desire for more opportunities to enhance their communication skills when dealing with families and to receive training about the safe and sensitive management of death scenes. They also emphasize the importance of taking collective responsibility for ensuring safety in their roles.41,42 Having a deeper understanding of medical knowledge and a clear sense of their roles and responsibilities in emergency situations can reduce paramedics’ distress and enhance job satisfaction.43

The curriculum analysis for EMS education in Sweden revealed an imbalance in course content related to professional practice, which included a significant emphasis on medical knowledge and a lesser focus on caring and contextual knowledge.44 Paramedics should be equipped with non-technical skills, including but not limited to situation awareness, decision-making, communication, teamwork, leadership, stress management, and risk approaches. These skills are crucial for effective performance in emergency situations. The examination of clinical complaints and investigations into clinical errors are valuable tools for identifying required non-technical skills gaps in paramedicine practice.45

The overlap between paramedic roles and those of other healthcare professionals hindered safe practice by paramedics, but collaboration with other clinicians had a significant role in shaping their safety roles. EMS procedures demand decisions and actions that require interactions between paramedics and physicians. There is limited scientific evidence about clinical decision-making and actions/inactions within EMS.10 It has been shown that paramedics can determine preliminary diagnoses to a satisfactory level, but the level of precision varies depending on the type of illness or emergency. The peer-to-peer consultation system in case of non-access to physicians is an alternative strategy for preserving patient safety.46

Our review findings indicated that the EMS environment, facilities, equipment, and work demands influenced paramedics’ roles in ensuring patient safety. Frequent referrals and overcrowding are ongoing, significant issues with global implications, impacting both patients and paramedics.47 The prevalence of work-related injuries among EMS professionals is three times higher than in other occupational sectors.48–50 Safety-compromising behaviors exhibited by paramedics are significantly associated with fatigue and organizational stress.51 The fast-paced environment of the emergency department where time pressure can amplify any initial disagreements between clinicians and patients or their surrogates, leading to distress for all parties involved.52 Applying ergonomic science to improve the work environment, institutional policies, technological or engineering solutions can improve patient and staff safety.10

The importance of attitudes, behaviors, and cognitive aspects, as well as the significance of concerns regarding patient safety and the moral and caring responsibility of paramedics were underscored. The symptoms of moral injury among paramedics are strongly connected to the feelings of guilt and shame, which can be manifested as social isolation and emotional numbing, reflecting the emotional and psychological impact of their work.53 Paramedicine programs should aim to develop a patient-centered, safe, and responsive therapeutic relationship. Additionally, they should serve as a safety net during health exacerbations, offer health education, and promote accountability for patient well-being.54 Paramedics should possess skills to collect pertinent cues and exhibit the capacity to form rapid clinical impressions. It involves an interconnected and dynamic interplay between conscious and subconscious information processing.55 In situations with a higher risk of moral injury, social support and established relationships with colleagues are beneficial for paramedics, helping them cope with emotional challenges associated with practice.43

Barriers to fulfilling expectations and obligations associated with paramedic roles included issues related to coordination, the dispatch system, and organizational support, all of which posed challenges to paramedics in playing their roles. Barriers to safe handovers between EMS and emergency departments are redundancy, poor recall, conflicting goals and perspectives, technological issues, information degradation, lack of standardization and training, delays, and absence of feedback mechanisms.56 Communication between the EMS and the emergency department, both before and upon arrival, along with a written patient report, efficient teamwork, and a conducive learning environment, are essential for patient safety.57,58 The decision-making process for non-conveyance by paramedics involves competencies, experience, intuition, consideration of the patient’s health status, their refusal, wishes, and utilization of supportive tools.59 Careful assessment and on-scene treatment is essential to ensure patient safety and reduce unnecessary transfers to emergency departments.60

Unsupportive workplace cultures have a detrimental effect on paramedics, impacting their mental health. This is exacerbated by inadequate feedback mechanisms, which hinder the opportunity to learn from mistakes.61,62 Patient safety events are often underreported and are most likely associated with issues in communication, checking/verification processes, and teamwork.63 The primary shortcoming of EMS is the lack of receiving meaningful feedback that aims to improve both practice and system-focused interventions.64,65 Inadequate documentation and the improper utilization of information are primarily attributed to healthcare professionals and organizations as technical issues.66 Staff should be encouraged and empowered to identify clinical errors and voice their concerns to help prevent individual feelings of shame and fear of potential consequences.67

Strengths and Limitations

This is the first systematic review to integrate current international knowledge about the roles of paramedics in the improvement of patient safety and in relation to the role theory. Only 16 articles were discovered that specifically examined the roles of paramedics in ensuring patient safety. With patient safety being a paramount concern in healthcare, the limited existing knowledge hinders our ability to fully understand and improve safety protocols and practices specific to EMS.

Language bias might have affected this review focused on studies published in English language, potentially excluding relevant research in other languages. Selection bias was avoided in this review considering the inclusion studies from both qualitative and quantitative designs. However, varying quality of included studies and the challenge of synthesizing data from heterogeneous sources with diverse study designs and methodologies could have influenced the research synthesis.

Future research is essential for bridging the existing knowledge gap and holding the promise of saving lives, reducing medical errors, and ultimately enhancing the quality of EMS. As EMS continues to evolve and face new challenges, there is a growing imperative to conduct comprehensive investigations that inform evidence-based strategies, enhance training, and bolster patient safety within this dynamic environment.

Conclusion

Our review findings shed light on critical factors influencing attitudes, behaviors, cognitions, and the ability of paramedics to play their pivotal roles in preserving and improving patient safety within EMS. The evolving role of paramedics in primary care and emergency settings necessitates further elucidation to maximize their clinical contributions and enhance healthcare delivery.

Paramedicine operates at the dynamic juncture of advancing technologies, diverse responsibilities, and intricate healthcare environments, necessitating a multifaceted approach. A comprehensive approach that systematically evaluates the entire patient flow system in EMS is required. In practice, it underscores the critical need for comprehensive training and education programs aiming at addressing decision-making, non-technical and technical skills for bridging the gap between theoretical knowledge and practical application, ultimately ensuring the safety and well-being of both paramedics and patients.

The development and implementation of standardized educational and training programs, and appropriate guidelines and protocols are equally essential to ensure that paramedics can perform their assigned tasks effectively and safely. Recognizing paramedics roles and capabilities and fostering collaboration between paramedics and other healthcare professionals can lead to more cohesive and patient-centered care.

Addressing the environmental and equipment-related factors in EMS is crucial to enhance the quality of patient care. A supportive workplace culture for paramedics indicates the significance of cultivating a work environment that is centered on continuous learning and development through robust feedback mechanisms based on patient outcome, peer assessment, and incident reporting.

The need for improved coordination and dispatch systems to facilitate the fulfillment of expectations and obligations associated with paramedic roles is highlighted. The intricacies of non-conveyance decision-making by paramedics, influenced by the myriad of factors related to professionals, patients, healthcare systems, and support facilities, underscore the need for well-defined protocols and competencies to safeguard patient care.

By recognizing and addressing these barriers and considerations, healthcare organizations and policymakers can take concrete steps to enhance patient safety and the effectiveness of paramedics in EMS.

Disclosure

The authors report no conflicts of interest in this work.

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