Joint Commission Highlights Importance of Crash Cart Preparedness

PUBLISHED: May 11, 2017
Relevant to: Ambulatory Care, Hospice, Hospitals, Long Term Care

The Joint Commission released Quick Safety Issue #32 reviewing the importance of crash cart preparedness – ensuring that facility crash carts are ready for use in the moment they are needed.

TJC’s Quick Safety review highlights a study done by the Pennsylvania Patient Safety Authority that found, over the course of a 12-month review, 56 reports of emergent situations where the facility crash cart was either missing supplies or supplies were outdated. TJC cites numerous contributing factors to patient safety events involving crash carts, including but not limited to:

  • 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/cart tampering
  • Carts secured in a manner that prevents immediate use (e.g., duty taped, padlocked)
  • Incorrect size of equipment
  • Lack of proper cart inspection
  • Cart access delays related to missing or misplaced carts

TJC’s review presents two case studies that use electronic solutions to keep crash carts ready for use. One facility uses a web tracking system and another implemented a sealed tray system and database that allowed for tracking of equipment availability and standardization. However, there are many non-technology based strategies that facilities can utilize to improve crash cart readiness.

  • Conduct a risk assessment that includes:
    • Staff training and education
    • Location of crash carts
    • Contents of crash carts
  • Evaluate risks and needs
  • Implement and continually reassess solutions

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