HSSIB investigation: 12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence (27 March 2025)

Summary

An ECG is a test that records the electrical activity of a patient’s heart. It needs to be correctly carried out and accurately interpreted to determine the patient’s condition and potential diagnosis. This Health Services Safety Investigation Body (HSSIB) investigation was prompted by the case of a 29-year-old woman with chest pain. Her ECG was misinterpreted and she later died of a heart attack. 

The investigation focused on paramedic education, training and competence in ECG practice and the task of carrying out and interpreting an ECG in the context of the patient’s clinical signs and symptoms. The investigation spoke to key stakeholders to understand the safety risks that may be present in this area. The way 12-lead ECGs are undertaken and interpreted was identified as a growing area of concern, with systemic safety risks that can have a significant impact on the outcome for patients.

HSSIB identified safety learning for ambulance services to help train qualified paramedics. It has also made a safety recommendation to the Health and Care Professions Council and the College of Paramedics to improve undergraduate teaching for paramedic students, to reduce this safety risk for patients.

Content

HSSIB makes the following safety recommendation

HSSIB recommends that the Health and Care Professions Council and the College of Paramedics work in collaboration with relevant stakeholders to improve the undergraduate teaching of 12-lead electrocardiograms by reviewing and updating any relevant standards, guidance, and curricula to provide clarification on:

• the level of education and expected level of competency and assessment required of student paramedics in relation to electrocardiograms
• any minimum expected standards for electrocardiogram education in higher education institutions, including the time spent on electrocardiogram learning, methods used, and subject matter expertise required of teaching staff
• how patient protected characteristics, health inequalities and other specific patient factors are taught in relation to electrocardiograms
• how effective feedback mechanisms can be developed between higher education institutions and ambulance services.

This is to help improve consistency in the way paramedic students are educated about electrocardiograms.

HSSIB makes the following safety observations

• Ambulance services can improve patient safety by including patient protected characteristics, health inequalities and other specific patient factors that can impact on the task of carrying out and interpreting a 12-lead ECG, when developing refresher training.
• Ambulance services and national organisations can improve patient safety by providing and supporting protected time and resources for paramedic training and continuous professional development, while understanding the potential impact on operational performance.
• Ambulance services can improve patient safety by providing additional support to paramedic students and paramedics through exposure to a range of clinical scenarios that help develop and maintain 12-lead ECG competency on a regular basis.
• Acute hospitals and ambulance services can improve patient safety by developing local mechanisms to share information about patient outcomes where paramedics have undertaken a 12-lead ECG. This can help to support learning for paramedics and provide feedback on where their practice may be improved.