The Crash Cart Checklist: Is It Enough to Reduce Patient Risk?
The Essential Crash Cart
The purpose of a crash cart is to store and transport emergency medication and equipment, providing physicians and nurses immediate access to life-saving items. One report by the National Hospital Ambulatory Medical Care Survey found approximately six million patients were triaged into the “immediate category” in emergency departments across the United States in a single year. This means the patient’s condition was so dire, they required a doctor within 60 seconds of arrival.
The World Journal of Emergency Medicine believes crash carts are, therefore, an “essential tool for resuscitation.” Their report entitled, “The Emergency Department Crash Cart: A Systematic Review and Suggested Contents” goes on to outline specific suggestions for the Emergency Department Crash Cart. From the items typically placed on the outside of the cart to items in each of the drawers, the report is more of a guide to a crash cart checklist.
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While every hospital and healthcare facility may have differing crash cart checklists, the items listed in available documents, such as that of the World Journal of Emergency Medicine, provide a good starting point. Every crash cart should be located near resuscitation areas, typically in emergency departments. They may also be needed near surgery departments in case of a surgical patient suddenly experiencing life-threatening symptoms. Pediatric units, too, should have their own crash carts with specialized items made for smaller bodies.
These are great suggestions, but there is more for hospitals to do to reduce patient risk.
The Risk Crash Carts Present
Crash carts enable physicians and trained healthcare providers to provide emergency care to critical patients, but if not maintained properly, can actually cause more harm than good. The Joint Commission provides an interesting article about crash cart preparedness – how missing or outdated equipment and medications on the crash cart have led to risks to patient safety.
It lists some of the most common events where the processes around crash carts can present a safety risk to patients:
- Medication errors and mix-ups
- Missing, expired, damaged, contaminated, and unavailable equipment or medications
- Empty oxygen tanks
- Drained batteries on equipment or equipment failure
- Unsecured carts or carts that have been tampered with
- Carts secured with heavy-duty tape and/or padlocks, preventing immediate access
- Incorrect size of equipment
- Carts not checked or inspected according to policy and procedure
- Staff is unable to locate the crash cart, resulting in a delay in getting emergency equipment to the bedside
- Staff is unfamiliar with the items regularly stored within the crash cart
- Staff is unfamiliar with the procedures for using the crash cart when responding to a life-threatening emergency
- Staff is unfamiliar with procedures regarding how to stock or restock the crash cart
Solutions to a Few Risk Factors
All of the above risk factors can be easily reduced simply by taking preventative precautions. We’ve listed out suggestions for these common issues in hopes that hospitals can take immediate action to ensure their crash carts and the protocols around them reduce patient risk.
Medication Errors and Mix-ups
Crash carts contain medications. Everything from Benadryl and aspirin to epinephrine and adenosine. In an emergency, time is of the essence, making the risk of grabbing the wrong life-saving medication increase. The crash cart should have these medications clearly labeled in large font and placed in the proper drawer(s) so they are easily accessible. Color-coding these medications can also help reduce risk. For instance, all medications related to cardiac issues can be in red bins. Medications for respiratory issues can be placed in blue bins. A crash cart checklist should include each medication on the cart under its appropriate colored heading.
Several of the issues above fall into this category: Missing, expired, damaged, contaminated, and unavailable equipment or medications; empty oxygen tanks; and drained batteries on equipment or equipment failure. When crash carts are used, there must be an established protocol to rapidly assess which items need replenishing. For instance, as soon as a crash cart is used and there is no longer a need for the cart, nurses can place the cart in a designated area for immediate review. An assigned staff member can be alerted and conduct the review. Their job is to go through the crash cart checklist and ensure every item is available or restocked. This is also a good time to check medication expiration dates and oxygen tank levels, verify all sterile equipment/supplies are still intact, and monitor battery life on equipment.
Unsecured or Improperly Secured Carts
Because crash carts contain drugs and life-saving equipment, it is critical for them to be properly maintained. Hospitals must invest in modern crash carts with security mechanisms that detect unauthorized access to any of the drawers that contain sensitive items. When security devices are used, the intent would be to use an appropriate device that allows the organization to detect tampering while not creating a barrier or delay in the staff’s ability to access the emergency supplies contained within the cart.
Something as simple as not being able to locate a crash cart can have dire consequences. Crash carts may be down the hall, on another floor, or in a stockroom being reloaded when they are needed most. Hospitals must invest in enough crash carts to ensure at least one is available at all times in the areas where they are most used. These carts should be located in emergency departments, labor and delivery floors, pediatric units, and surgical floors. Further, the location of these crash carts should be posted in every area of the hospital. Clear signage of where to find crash carts or a number a nurse can call to have a crash cart delivered is helpful. Hospitals should also leverage mobile transfer carts where medications and supplies can be brought to the crash carts instead of removing the crash carts from their emergency locations to be restocked.
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If staff members are unfamiliar with the carts, items on the crash cart checklist and how they are to be stocked, or how to use the crash cart, lives are at risk. Every physician and nurse who cares for critically-ill or injured patients must be properly trained on all aspects of crash carts. This may include classroom training, departmental training, or online training. Any time a new medication or life-saving item is placed on the cart, staff must be trained on why the item was added, where it is located, and how and when it should be used. Staff members should also have time to personally familiarize themselves with the actual cart they would use, opening drawers and surveying its contents and going through the crash cart checklist to find where each item is located.
The Crash Cart Checklist
Every crash cart should have a checklist. This gives staff an easy and fast way to see what they should expect to be on each cart. It also gives those staff members who stock the carts an item-by-item inventory of what they must ensure is actually on the cart, and in good working order. The crash cart checklist must be attached to the outside of the cart so that it is unmovable but easily seen. It should also be laminated in order to maintain its integrity.
Again, as the hospital or department using the crash carts decides to add or remove items, the crash cart checklist must be updated immediately to reflect the changes. These modifications should be communicated with all stakeholders so there are no surprises during an emergency.