Introduction Decisions made by ambulance staff are often time-critical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system influences on decision making in the ambulance service setting focusing on paramedic roles.

Method An exploratory mixed methods qualitative study was conducted in three Ambulance Service Trusts. A document search and 16 interviews were conducted to understand service delivery in each Trust, how they link with other services and potential influences on decisions about patient care. Researchers observed ambulance crews on 34 shifts and 10 paramedics completed ‘digital diaries’ to report challenges for decision making or patient safety. Three focus groups with staff (N=21) and three with service users (N=23) were held to explore their views on decision making and patient safety. Data were charted to produce a typology of decisions then coded and thematically analysed to identify influences on those decisions.

Findings Nine types of decision were identified, ranging from specialist emergency pathways to non-conveyance. Influences on these decisions included communication with Control Room staff; patient assessment, decision support and alternative options to ED conveyance. Seven main issues influencing patient safety in decision making were identified: meeting demand; performance and priorities; access to care options; risk aversion; education, training and professional development for crews; communication and feedback to crews; resources and safety culture.

Conclusions A range of decisions are made by ambulance staff in complex, time bound changing conditions. Training and development and access to alternative options to ED conveyance were identified as particularly important issues.