Patient Safety Topics
:
Emergencies, Clinical
Overview

The Pennsylvania Patient Safety Authority revewed events reported during a 12-month period to determine whether or not there may be an issue with event reports related to crash carts and missing or unavailable equipment, specifically during a clinical emergent or rapid response situation. The review identified 56 reports that highlighted emergency or rapid response situations in which supplies or equipment were missing or outdated. The locations of these incidents varied as did the types of medical emergencies, but the common theme was lack of the appropriate equipment and supplies to successfully manage the emergency in a timely manner. Reports identified issues such as incorrect size supplies, missing items, empty oxygen tanks, drained batteries on equipment, or unstocked or unlocked crash carts.

Key Data and Statistics

Analysis of the events reported to the Authority and review of the literature identifies three factors of clinical emergency preparedness that warrant attention in virtually every clinical point of care area:

  1. having rapid access to functioning equipment and up-to-date supplies;
  2. having knowledgeable and trained staff to manage the clinical emergency; and
  3. once systems are in place, monitoring those systems to ensure that clinical staff maintain a state of readiness to manage clinical emergencies.

As an example, the Table correlates events by location reported to the Authority with the failure modes identified in an failure mode and effects analysis tool. 

Table. Pennsylvania Patient Safety Authority 2008 Reports and Corresponding Failure Modes ​ ​
Location of Event Description of Report Failure Mode*

Cardiac intermediate unit

The crash cart defibrillator battery was dead. The oxygen tank was empty.

Failure to identify expired materials.

Cardiac unit

[There was an] expired code cart. It was not replaced until 24 hours later.

Code cart refurbishment does not occur after usage and will be missing essential items. No one responsible for delivery, maintenance, or refurbishment.

Cardiology—invasive

During code/intubation, staff found a suction canister on the code cart that was not functioning. Equipment services examined the suction apparatus and determined the regulator was broken. The equipment was removed from service.

Failure to identify expired materials.

 

Ambu bags were missing from the code cart. Suction was not located in the proper place.

Incomplete list of items in the crash cart.

Cardiovascular/surgical intensive care unit (ICU)

Patient was in ventricular fibrillation. The defibrillator on the crash cart would not charge on paddles. The second defibrillator was readily available for use. The patient was successfully defibrillated.

Failure to identify expired materials.

Emergency department (ED)

Staff discovered [during a] check of crash cart drawer that only one epinephrine [injection was] used. Two epinephrine [injections were] ordered by the doctor. The patient was in cardiac arrest. [The patient arrived at] ED via ambulance. Patient was in ventricular fibrillation/asystole on arrival. Nurse involved was unable to reconcile discrepancy.

The crash cart was used for this patient during the night. The [ED registered nurse (RN)] never called for the crash cart to be replaced, and the open cart was not found until a code was called during the next shift. [There was an] issue of safety with a used crash cart open on the unit.

One of the crash carts in the ED was opened [in the afternoon] and the pharmacy was not called until [the following morning] to replace the cart. [There was a] safety issue with an open crash cart if it was needed for a true code. Policy states the cart is to be replaced after being opened for any reason.

Crash cart refurbishment does not occur after usage and will be missing essential items. No one responsible for delivery, maintenance, or refurbishment.

 

During rapid response, a patient needed to be intubated and the intubation box had no stylet. The RN needed to go to another unit to get a box with a stylet. The patient's intubation was delayed five to eight minutes.

Incomplete list of items in the crash cart.

Medical/surgical/cardiac intermediate unit

An intubation 16 Fr stylet was unavailable on the code cart. A stylet was retrieved from another code cart located on floor. No harm [occurred].

A code was called and the [code] cart was opened [during the morning] The floor [staff] did not call the pharmacy to exchange the open crash cart until [late afternoon]. [There was a] safety concern that an open, incomplete [code] cart was on the floor for several hours without being exchanged.

Code was called for this patient. [Staff] did not call to have the [code] cart replaced until [late afternoon]. Cart was not cleaned up before the exchange, and used needles and a blade were left lying on top of the cart. Medications were used also. [There was a] safety concern with a partial cart on the floor for five hours.

The orange resuscitation bag [was discovered] opened [during response] to a patient needing to be intubated. Propofol and succinylcholine missing from bag. Medications obtained and patient intubated.

Code cart refurbishment does not occur after usage and will be missing essential items. No one responsible for delivery, maintenance, or refurbishment.

 

A code was called and when the physicians went to place a central line, there was no central line insertion kit on the code cart.

A code was called. [There was] no monitor on the unit. The labor and delivery staff did not bring their monitor initially.

Reported inadequate supplies with rapid response called. The patient was transferred to the ICU.

Incomplete list of items in the code cart.

 

There was no adult bag valve mask in the [code] cart during a cardiopulmonary arrest resuscitation. The code sheets on the clipboard were in the utility room instead of on the cart. The appropriate equipment was obtained from ICU and utility room. The [code] cart was restocked with medications and supplies.

Personnel working off of different check sheets for inventory.

 

There was a code situation, and the airway box was needed. The box was labeled with an expiration date that had past. Upon opening the box, there were no endotracheal tubes. The patient had to be bagged until the airway box from the ICU was brought out with the proper supplies in it.

Failure to identify expired materials.

Medical ICU

Code cart opened. All epinephrine boxes in drawer had needles on them. Not able to use.

The patient's heart rate was greater than 160 beats per minute and sustained. Following American Heart Association advanced cardiac life support guidelines, adenosine was [administered intravenously]. There was not adequate stock of adenosine in crash cart to give recommended protocol. The patient was transferred to the ICU and cardioverted. A normal heart rhythm was obtained.

During a code, staff found that [code] cart only had one size of Mac blade. The physician was aware.

Incomplete list of items in the code cart.
 The red respiratory box on the low side of code cart was found to be unlocked and dirty.

Code cart refurbishment does not occur after usage and will be missing essential items. No one responsible for delivery, maintenance or refurbishment.

Outpatient dialysis unit

The Ambu bag was pulled off the code cart; the bag was sealed. When Ambu bag was opened, there was no mask in bag. [Staff were] unable to use Ambu without mask. The patient needed to be resuscitated with a nonrebreather mask.

During a code, it was noted that the triple lumen tray was not on the code cart. [Staff] used dialysis needles until triple lumen tray was obtained.

Incomplete list of items in the code cart.

Orthopedic unit

A patient coded and the Ambu bag on code cart did not have a mask. The patient was intubated.

Incomplete list of items in the code cart.

Outpatient area

[The patient] became unresponsive. The rapid response team was called. The code cart was brought, but then taken away. Supplies to treat the patient, including intravenous (IV) supplies were not available.

Incomplete list of items in the code cart.

Pediatric unit

Yankaur, suction tubing, and IV tubing were missing from the crash cart during a code.

Incomplete list of items in the crash cart.

 

The replacement crash cart lock was never locked when received from central.

Crash cart refurbishment does not occur after usage and will be missing essential items. No one responsible for delivery, maintenance or refurbishment.

Pharmacy

A code [occurred in early morning], but no replacement crash cart was available [and none were nearly four hours later]. Central [was requested] to page nursing director when one was ready. [This was the] second time [in a] week the issue occurred in which approximately three to four hours without a crash cart [available].

Crash cart refurbishment does not occur after usage and will be missing essential items. No one responsible for delivery, maintenance, or refurbishment.

Rehabilitation unit

A [patient] was transported to the hospital's outpatient rehabilitation unit for therapy. While in the rehab unit, the patient became unresponsive. A code was called. During the code, it was discovered that the oxygen on the crash cart could not be used because the spigot was missing. Other tanks in the unit were empty. The reporting facility amended the report to indicate that other oxygen tanks were available for use.

[Cardiac] monitor was applied to patient but was not working properly [no rhythm]. Patient monitored by electrocardiogram machine until crash cart/monitor obtained. [There was] no delay in monitoring. The monitor was tagged and sent to central.

Incomplete list of items in the crash cart.

Telemetry unit

Stylet was not replaced in crash cart after last event.

Incomplete list of items in the crash cart.

* Source of failure modes is as follows: Long EK. Crash cart standardization. 2007 Jan 31 [cited 2009 Apr 30]. Available from Internet: http://www.ihi.org/ihi/workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=5431&ScenarioId=6443&Type=1. ​

 

Excerpted from: Clinical emergency: are you ready in any setting? Pa Patient Saf Advis 2010 Jun. http://patientsafety.pa.gov/ADVISORIES/Pages/201006_52.aspx.

Educational Tools

Missing Items and Equipment with Suggested Action Plan
Identifying equipment failures as well as missing equipment may assist facilities in ensuring the development of thorough emergency checklists that address the specific needs of the unit’s patient population.​

Emergency Crash Cart Checklist
Facilities may find this sample checklist for the crash cart useful to ensure that the emergency supplies and equipment are periodically monitored and evaluated.

Multimedia

​Visit this section in the future for any multimedia associated with this patient safety topic.

Advisory Articles

 

Safety Tips for Patients

 

 

©2018 Pennsylvania Patient Safety Authority