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key takeaways

  • Crash carts continue to be a common source of preventable risk in Code Blue care.
  • In a 2022 report by The Joint Commission, missing/expired items on crash carts ranked in the top 5 top clinical problems found by surveyors (outside of infection control or suicide prevention).
  • Now more than ever, innovation in crash cart technology is needed to prevent costly mistakes in a life-or-death emergency.

In 2017, The Joint Commission (TJC) reported in a Quick Safety bulletin that many crash carts have “hidden issues” that could contribute to patient safety events. Those findings were based on a 2008 study from the Pennsylvania Patient Safety Authority, which identified 56 reports of missing or outdated emergency supplies/equipment in a 1-year period.1 Common crash cart safety issues included medication errors and mix-ups, drained batteries, missing equipment, unsecured carts, and more.1

With over a decade passed since that study was done, it’s worth asking: What has changed since then?

Not enough, according to findings from TJC surveyors over a 12-month period that ended in August 2022. The results, which were included in a discussion of 2022 scoring trends at the Hospital Executive Briefing held in September, showed that issues with crash carts are among the top clinical problems found by surveyors.2

Keep reading to learn about the specific crash cart findings discussed, tips to improve TJC crash cart compliance, and our most important takeaways from the briefing.

TJC executive briefing: summary of findings


The discussion of 2022 scoring trends was led by Maura Naddy, MSN, RNC-OB, CJCP, the Senior Associate Director with TJC’s Standards Interpretation Group Operations & Quality Assurance Department.

Naddy reported that outside of infection control or suicide prevention, expired or missing items on crash carts was one of the top 5 clinical problems found by surveyors.2 Other issues in the top 5 included medication verification, food and nutrition storage, informed consent, and pain reassessment.

Crash-cart specific findings

The crash cart findings focused on standard PC.02.01.11, EP 2: Resuscitation Equipment: “Resuscitation equipment is available for use based on the needs of the population served. Note: For example, if the hospital has a pediatric population, pediatric resuscitation equipment should be available.”3

Naddy offered some practical, real-life examples of what findings in this category might look like2:

  • Pediatric pads unavailable for automated external defibrillator (AED) equipment and/or AEDs not charged
  • Expired medications on the cart
  • Supplies not available for an event (e.g., if a crash cart is being used to care for a mother with a child, are there supplies to support the child as well?)

As to severity, 21.2% of the deficiencies in this category were high-risk according to TJC SAFER Matrix, the risk scoring method used by TJC surveyors. 69.1% were in the moderate-risk category.2

Tips to improve TJC crash cart compliance

So what precautions can hospitals take to avoid these pitfalls and improve TJC crash cart compliance? Naddy suggested the following2:

  • Keep crash carts in an easily accessible location and make sure staff members know where to find them quickly in an emergency.
  • Make sure there are enough carts available within the unit and for the facility.
  • When stocking the cart, account for different patient populations and scenarios (e.g., pediatric patients as well as adults).
  • Review crash cart policies for ensuring resuscitation equipment is ready for use. Who is responsible for checking cart supplies each shift? What is the process for removing and restocking a used cart?
  • Hold drills with different scenarios to identify any gaps. Did staff know where to go to locate the cart? Did they have all supplies needed for that particular mock scenario?

For additional tips on crash cart compliance, check out our article on preparing crash carts for a regulatory survey.

Our take

In a medical emergency, details matter

One of Naddy’s comments from the discussion stands out in particular: “It may seem like it’s the little things that get scored, but in an emergency those things may save a life.”2

Naddy hit on a crucial point that helps explain why crash cart management is essential, but so easily overlooked: In a medical emergency, the little things become the big things. An expired medication, drained batteries, a missed or incomplete cart check. These issues may seem minor in the moment. But when a patient’s life is on the line and every second counts, they become costly.

Innovation in crash cart technology is needed — now more than ever

The problem? Despite technological advancements elsewhere in the hospital, crash carts at most hospitals today are stuck in the past. This means that cart checks and other cart safety tasks are manual, time-consuming, and inherently error prone. Simply put, staff members don’t have the right tools to prevent these kinds of oversights from happening.

Yes, hospitals should implement the changes Naddy suggests and take as many manual precautions as they can regarding crash carts. Utilizing cart checklists, standardizing cart organization, and other strategies can help reduce risk — to an extent. But the reality is that manual processes are inherently flawed, and efforts to improve their accuracy will only go so far.

The better solution — and the one that’s more likely to have a lasting impact — is to give staff the tools they need to be successful. Automating many of the crash cart tasks that are manual today would go a long way toward reducing the common errors noted by TJC. Crash cart automation would bring much-needed features such as:

  • Searchable cart inventory to remove recalled products before they inadvertently reach a patient
  • Automated upcoming expiration notifications to ensure all medications and supplies on the cart are safe and usable
  • Standardized templates for crash cart supplies to enable easy access to items in a life-or-death emergency
  • Electronic reconciliation of used items after a Code Blue to automate awareness of crash cart restocking needs for medications and supplies
  • Built-in tracking, notifications, & reporting to ensure cart checks are happening consistently and per protocol
  • Electronic monitoring of crash cart access to increase crash cart reliability, detect tampering, and simplify post-tampering cart checks

Until this happens, staff will continue to be hampered by the limited technology available. And crash carts will continue to be an all-too-common source of preventable risk in Code Blue care.


Nuvara® can help

The EMMIT® Emergency Care System from Nuvara can help your hospital streamline crash cart processes, avoid costly errors in an emergency, and improve TJC crash cart compliance.


  1. The Joint Commission. Crash-cart preparedness. Quick Safety. 2017 Apr;32:1-3. Available at: Quick Safety 32: Crash-cart preparedness | The Joint Commission
  2. Plunkett, AJ. (2022). Executive Briefing: Medication Orders, Crash Carts, and Food Storage Lead Top Clinical Problems. Accreditation Insider. Available at: Executive Briefing: Medication Orders, Crash Carts, and Food Storage Lead Top Clinical Problems – Patient Safety & Quality Healthcare (
  3. The Joint Commission. (2021). R3 Report: Resuscitation Standards for Hospitals. Available at: r3-report_resuscitation_hap_final_.pdf (
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