Optimizing Crash Cart Efficiency: A Comprehensive Guide to Enhancing Patient Safety


In the high-stakes world of healthcare, the readiness of your organization’s crash carts can mean the difference between life and death. Often, these emergency response tools, also known as emergency carts, bags, or boxes, harbor hidden issues that can potentially compromise patient safety.

The Hidden Dangers in Crash Carts

While much of the discourse around crash cart-related safety incidents revolves around medication errors, it’s crucial to ensure that your crash cart is primed for any life-threatening emergency. This could involve a patient, staff member, or visitor. A 2008 review by the Pennsylvania Patient Safety Authority revealed 56 reports of emergency situations where supplies or equipment were either missing or outdated. Out of these, 35 were related to crash carts, and 21 involved missing supplies or malfunctioning equipment during emergencies.

Factors Contributing to Crash Cart-Related Patient Safety Incidents

Several factors can contribute to patient safety incidents involving crash carts. These include:

Medication errors and mix-ups

Missing, expired, damaged, contaminated, or unavailable equipment or medications

Empty oxygen tanks or drained equipment batteries

Unsecured or tampered carts

Carts secured with heavy-duty tape or padlocks, hindering immediate access

Incorrect equipment size

Carts not inspected according to policy and procedure

Staff inability to locate the crash cart, leading to delays in emergency equipment delivery

Staff unfamiliarity with the items in the crash cart or the procedures for using and restocking it

While these issues may seem minor, they can cause delays in care provision, posing a significant patient safety risk. By enhancing the efficiency and reliability of your crash cart, you can improve patient outcomes following a crisis event.

Innovative Strategies for Crash Cart Efficiency

Several organizations have successfully implemented electronic solutions to keep crash carts ready for emergencies. For instance, a large hospital developed a web-based crash-cart tracking system that replaced paper logs, enabling remote tracking and monitoring of crash cart checks, alerting staff to near-expiry items, and identifying areas for improvement.

In a 2014 study by the Heart of England NHS Foundation Trust, three hospitals implemented a sealed tray system and database that improved equipment availability, traceability, and standardization. This system reduced the complexity of the checking process and prevented clinicians from “borrowing” emergency equipment.

Safety Actions to Consider

Medical emergencies can create a sense of chaos. This feeling can be amplified if the necessary emergency equipment is not readily available. The purpose of a crash cart is to ensure that the correct emergency equipment, medications, and supplies are readily available to manage the emergency.

Risk Assessment and Mitigation

Start with a risk assessment to identify risk points and their origins. These can include staff training and educational needs, the location of crash carts, and the contents of the crash carts. Monitor data related to specific issues identified as contributing factors to unsafe incidents concerning crash carts and emergency equipment. Evaluate and analyze these risks independently and collectively to determine the best solution.

Taking Action and Sustaining Improvements

Develop an action plan, implement it, and continuously reassess and revise to ensure that your crash carts and staff are ready for life-threatening medical emergencies. This plan should address equipment, supplies, medications, inventory management, emergency protocols, staff training and competency, emergency drills, and assignment of responsibility for continued oversight of the process.


In many hospitals, crash cart stocking and replenishment may be handled by another department, such as the pharmacy or central supply. If this is the case, representatives from these areas should be involved in the needs assessment and included in the written plan. By taking these steps, you can ensure that your organization isprepared to handle any emergency situation effectively and efficiently, thereby enhancing patient safety and outcomes.

Additional Resources

For further reading and resources, consider the following:

Pennsylvania Patient Safety Authority: Clinical Emergency: Are You Ready in Any Setting? Pennsylvania Patient Safety Advisory, June 2010;7(2)52-60.

M Davies, et al: A Simple Solution for Improving Reliability of Cardiac Arrest Equipment Provision in Hospital. Resuscitation, 2014(85)1523-1526.

S Sones: Is Your Code Cart Ready? Outpatient Surgery, October 2008.

AM Pearson, et al: Crash Cart Drug Drawer Layout and Design. Proceedings of the Human Factors and Ergonomics Society 56th Annual Meeting 2012. Human Factors and Ergonomics Society Inc.

Are You Ready for an Emergency? Don’t Get Caught Unprepared. Same-Day Surgery, September 2010;34(9)97-101.


This article is intended solely as an informational guide and does not constitute a standard or a Sentinel Event Alert. The aim is to raise awareness and provide helpful insights to Joint Commission-accredited organizations. The information is derived from actual events that occur in healthcare.

By ensuring that your crash carts are well-maintained and ready for any emergency, you can significantly improve patient safety and outcomes. Remember, in the world of healthcare, being prepared can make all the difference.