Shared learning · changes-implemented log · safety messaging
6
All themes
5
Action complete
1
Owner-tracked
12
Bulletins · CPDs · briefings
Source: DTX-2026-0118
Summary
Following SUI investigation into delayed pad placement during paediatric arrest, the storage location of paediatric defibrillator pads was found to vary across the fleet.
Change Implemented
All front-line vehicles now carry a sealed paediatric grab-bag in the front-left side of the resus drawer, with pads visible through a clear panel. Make-ready checklist updated.
Shared Via
Owner · Dr Priya Sharma — fleet sweep complete; quarterly check added to rolling audit programme.
Source: DTX-2026-0117
Summary
Reminder that PGD §4.3 requires retrospective second-check documentation when only one clinician is present at administration.
Change Implemented
PGD documentation prompt added to PRF e-form. Reinforced at April CPD.
Shared Via
Owner · Thomas Clarke — closed at April CPD attendance review.
Source: DTX-2026-0116
Summary
Low-speed contact during a blue-light reversing manoeuvre prompted review of in-house driver assessment programme.
Change Implemented
All blue-light drivers to complete a 30-min reversing/observation refresher at next CPD. Signed-off by Brookwood Workshops driver-trainer.
Shared Via
Owner · Thomas Clarke — programme delivered; closed.
Source: DTX-2026-0114
Summary
Equipment fault highlighted gap in awareness of when MHRA Yellow Card reporting is required.
Change Implemented
Quick-reference Yellow Card poster added to all vehicles. Training pack updated.
Shared Via
Owner · Thomas Clarke — closed.
Source: DTX-2026-0112
Summary
Near-miss between 1:1000 and 1:10,000 adrenaline ampoules in drug bag layout.
Change Implemented
Drug-bag layout standardised across fleet. 1:10,000 ampoules now in a red-lined sleeve. Visual reference card updated.
Shared Via
Owner · Dr Priya Sharma — drug-bag refresh completed across fleet.
Source: CON-2026-004 (concern)
Summary
Multi-agency feedback that scene coordinator role was unclear at RTC. JESIP joint-decision model touchpoints not always visible.
Change Implemented
High-vis tabards now carried on all front-line vehicles labelled "AMBULANCE COMMANDER". JESIP refresher added to mandatory training.
Shared Via
Owner · Thomas Clarke — open: JESIP refresher to be re-run Q3 2026.