Introduction
Workplace injuries among paramedics remain stubbornly high, and many stem from in-the-moment decisions—rushing, skipping checks, or forgoing safety gear. This study asks whether a Behavior-Based Safety approach, adapted for a job with no on-site supervisor, can improve safety behaviors during real ambulance missions. For clinicians who support staff training or systems change, the findings offer a practical model worth understanding.
What is the research question being asked and why does it matter?
The main question was whether a Behavior-Based Safety (BBS) approach can improve safety behavior for paramedics during real ambulance missions.
This matters because paramedics get hurt at work often, and many injuries are linked to what people do in the moment—rushing, skipping checks, or not using safety gear. Paramedics work fast, in unfamiliar places, under high stress. Safety rules designed for factories may not fit. If a simple BBS plan can work in this setting, it gives leaders a practical way to reduce risk without adding equipment. For clinicians who support staff training or systems change, the key point is that “safety behavior” can be defined, observed, and improved the same way we do in other ABA work.
The study also matters because the authors adapted BBS to a job where no supervisor is present. Paramedics often work in teams of two and make many choices on their own, so safety support has to fit that culture. If your workplace is similar—small teams, high independence, changing environments—this study offers a model for how to start.
It also highlights that safety problems are not always about “bad attitudes.” Often they stem from unclear expectations, high effort, and weak feedback systems. That framing helps you plan solutions that respect staff dignity and real job demands.
What did the researchers do to answer that question?
The researchers worked with two emergency medical service stations and observed paramedics during ambulance calls. Before providing any feedback, they completed a safety assessment using a structured tool (the PDC-Safety) and gathered information from documents, staff interviews, focus groups, and on-site walkthroughs. They used this to identify likely barriers—safety goals that were too broad, or equipment that made safe behavior harder.
Then they held a design workshop with managers, safety experts, worker representatives, and paramedics to select and define the exact safety behaviors to track. This is important for practice: the checklist was shaped with staff input, not imposed by outsiders.
Next, they built a safety checklist with four areas: general safety, lifting/carrying, personal protective equipment (PPE), and infection control/hygiene. During each mission, a researcher rode along and scored each item as safe, at-risk, or not applicable, then calculated percent safe.
They used a multiple-baseline design across the two stations, starting the intervention at different times to help show that changes were linked to the intervention. The intervention had two main parts: task clarification (explaining the checklist and what “safe” means) and feedback. Feedback included posted graphs in a staff area plus short verbal feedback to the two-person crew right after the mission.
Overall “percent safe” improved from about the mid-50% range in baseline to the mid-70% range during intervention at both stations, with follow-up still fairly high months later. Some categories improved more than others, and PPE showed mixed maintenance across stations.
Major limitations: they could not measure interobserver agreement (only one observer could fit in the ambulance), the pandemic interrupted data collection, and the number of observation sessions was smaller than planned. Treat the results as promising but not certain. Focus on the parts that are easy to replicate: clear definitions, brief observations, and quick feedback.
How you can use this in your day-to-day clinical practice
If you supervise staff in high-risk, fast-moving work—field-based care, crisis work, community sessions, transport, or any setting with time pressure—start by defining safety as observable actions, not as “being careful.”
This study used a short list of behaviors like securing items before driving, using handrails on stairs, or safe handling of sharps. Your first step is to pick a small set of behaviors that are both important and likely to happen often enough to observe. If a behavior is rare, you won’t get enough data to guide coaching, and staff may feel the checklist is unfair. Keep the list short at first so it doesn’t feel like extra paperwork.
Do a quick safety assessment before you jump into feedback. In the study, staff often knew the correct rule but didn’t follow it in the moment because it took more effort or didn’t fit the workflow. In your setting, look for the same pattern: do people have the skill but not the follow-through? If yes, training isn’t the main fix—better prompts, lower effort, and better feedback are.
Also check if equipment makes safe behavior harder, like PPE that’s uncomfortable. Coaching alone won’t solve that. When you find an equipment barrier, treat it as an environmental variable needing a system change, not a “compliance problem.”
Build the checklist and scoring rules with the people who do the job. The researchers used a workshop with paramedics and leaders, which likely helped buy-in and made the definitions realistic. In practice, you can hold a 30–45 minute meeting with a few respected staff and ask: “What does safe look like when this goes well?” and “What does at-risk look like that we want to reduce?” Then write the items in plain language that matches the team’s real tasks.
This protects dignity because staff aren’t being judged by hidden rules. It improves fairness because expectations are shared.
Use brief feedback right after the event, and keep it balanced. In this study, observers reviewed the checklist after the mission and gave positive and constructive feedback.
If you adopt this, make the feedback short, specific, and tied to the defined items—like “You both paused before the vehicle moved and checked everything was secure,” rather than “Good job being safe.” When you give corrective feedback, focus on the next chance, not blame: “Next time, let’s do the secure check before pulling out.” This fits ABA coaching and is more likely to be accepted in teams that value autonomy.
Post simple trend data where staff will actually see it. The study posted graphs in a room paramedics used often, which increases the chance feedback becomes part of the routine. In clinical settings, pick one location staff naturally pass through—where they log notes or pick up materials. Keep the display easy to read, such as percent safe by week, and avoid using it to shame individuals.
The research used anonymous observations, which is a key dignity point. If you shift to staff-led observation, set clear rules that data are for team improvement, not punishment.
Plan for disruptions and maintenance from the start. The study was hit by pandemic shutdowns and management changes, and transferring the process to employees became difficult.
In your setting, assume staffing changes, schedule disruptions, and emergencies will happen. To reduce risk, teach the observation and feedback routine early to a small group of peer leaders—not just one supervisor. Keep the process low-effort: one short observation per shift, one minute of feedback. If it’s too heavy, it will disappear when workload rises.
Be careful about what this study does not show. It measured “percent safe” on a checklist, not actual injury rates, and it lacked strong reliability checks. Don’t promise this will reduce injuries for certain, or that it will work the same way in all teams. Treat it as a structured coaching and feedback system that can improve observable safety behaviors for some staff under some conditions. If you adopt it, build in your own quality checks—occasional second observations when feasible, or short calibration meetings where observers compare how they score a few scenarios.
Finally, avoid using BBS as a tool for control. Paramedics in the study described themselves as independent, and in many care settings staff will reject anything that feels like “gotcha” monitoring.
Frame the work as making it easier to do the safe thing under pressure. Invite staff to suggest changes that lower response effort. When staff can say, “This item is hard to do because the gloves are stored too far away,” you can fix the system instead of demanding more willpower.
That’s the main practical lesson: define safety clearly, observe briefly, give quick feedback, and keep the environment and culture in view the whole time.
Works Cited
Bördlein, C., & Kade, L. (2025). Behavior-based safety with paramedics. *Journal of Organizational Behavior Management, 45*(4), 361–377. https://doi.org/10.1080/01608061.2025.2454294
