WINSTON-SALEM, N.C. — At the North Carolina EMS Expo, Matthew Streger, Esq., delivered a keynote that cut across clinical care, operations, leadership and legal exposure with a single premise: EMS must define and eliminate its own “never events.” Not theoretical risks. Not rare complications. Preventable actions and omissions that carry a high likelihood of harm and for which safeguards already exist.
Streger, both paramedic and attorney, framed never events as those moments where failure is not due to complexity but to breakdowns in discipline, systems or culture. In hospitals, CMS ties payment to these events. In EMS, the consequence is more immediate and less forgiving. Patient harm, crew injury and liability.
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Clinical never events: the red lines
Streger laid out a practical clinical list that resonated because every item is familiar:
- Unrecognized esophageal intubation
- Medication error
- Untreated hypoxia during sedation
- ALS before BLS fundamentals
- Dehumanizing patient care
- Assuming drugs, alcohol or psychiatric causes without ruling out medical conditions
- Destination choice not aligned with definitive care
- Inappropriate or incomplete handoff
The airway example set the tone. There is no defensible scenario for failing to confirm tube placement with waveform capnography and an additional method. Confirmation is not a single moment. It is continuous. After movement, after transfer, at handoff and in the documentation.
The medication error prevention example was similarly direct.
- Verify the five rights.
- Use two people whenever possible.
- Build checklists into practice.
- Say the drug out loud.
- Show the vial.
- In single medic environments, introduce a structured self-check.
These are not advanced solutions. They are disciplined ones.
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Sedation and restraint carry a parallel obligation. Once a patient is sedated or restrained, monitoring must follow immediately. ECG, pulse oximetry and ETCO2 when available. The risk is not the intervention alone. It is the failure to detect deterioration.
Streger also challenged a persistent cognitive trap. Labeling a patient as “drunk” or “psych” too early narrows thinking and delays diagnosis. Altered mental status demands a full differential. Hypoxia, hypoglycemia, infection, stroke and trauma remain common, treatable and frequently missed when assumptions take hold.
Finally, destination matters. Transport decisions should be driven by where definitive care exists, not by habit, geography or convenience. The belief that a closer facility can stabilize and transfer often translates into delay and deterioration.
Operational discipline still matters
While the slides focused on clinical and administrative domains, the underlying message extended to operations. Restraints, seatbelts, secured equipment, stretcher handling, and lights and sirens use all represent predictable risk.
These are not edge cases. They are daily practices. When they fail, they fail visibly and often catastrophically.
Administrative never events: the quiet liabilities
The administrative list was equally direct:
- Patient contact without proper procedure and documentation
- Care delivered without informed consent
- Inappropriate restraint practices
- Working with expired or fraudulent credentials
- Equity violations in care or leadership
- Improper use of social media
- Failure to intervene when conduct is unsafe
These are the issues that surface later, in review, in court or in public scrutiny. Streger’s point was that they are no less preventable than clinical errors. A poor refusal process, an undocumented encounter or a shortcut in consent can undo otherwise sound clinical care.
Restraint practices were singled out.
- No hog tying.
- No non-clinical prone positioning.
- Continuous monitoring is required.
The legal and ethical expectations are converging, and EMS is not insulated from that shift.
Equity and professionalism were also addressed without ambiguity.
- Patients must be treated consistently.
- Personal bias, familiarity or frustration cannot shape care.
- Social media remains a recurring failure point.
- Images, descriptions or commentary from scenes have no place online.
Perhaps most pointed was the expectation to act. Even where formal duty is debated, the practical expectation is not. If something is wrong, attempt to stop it. Silence is increasingly viewed as complicity.
What to do next
The closing slide was not conceptual. It was operational:
- Fix policies, procedures and guidelines.
- Use checklists and cross checks.
- Do not do something wrong because a policy says so.
- Do not be lazy. Do not lie.
- Prioritize documentation and structured handoffs.
The emphasis on checklists stood out. Simple prompts before transport can prevent a cascade of failures.
- Is the patient restrained?
- Is the equipment secured?
- Is the crew secured?
- Are we going hot or cold?
- Where are we going?
These are not burdens. They are safeguards.
Equally important was the warning about policy. Policies should guide safe practice, not compel unsafe actions. If a policy conflicts with patient or crew safety, there must be a mechanism to deviate, document and justify.
Documentation and handoff remain foundational. A clear, structured report and accurate record are not administrative burdens. They are clinical tools and legal protections.
The takeaway on EMS never events
This session did not introduce new technology or complex clinical pathways. It focused on execution. EMS already knows how to prevent many of these events. The gap is not knowledge. It is consistency.
The practical challenge for agencies is straightforward.
- Define your own never events.
- Embed them into policy.
- Train to them.
- Audit them.
- Talk about them.
Because in EMS, the events that should never happen are often the ones we have normalized. That is the problem Streger put in front of the room. And it is one that sits squarely within the control of EMS leadership.
