Potential Hazard of Locked Cart

Daniel Yousif, MD

To the Editor:

I want to echo the comments of Martin Bogetz, MD, in the Summer 2001 APSF Newsletter. Our hospital is involved in a pharmacy-initiated trial of an anesthesia medication storage system. This system provides an anesthesia cart with a locking mechanism to secure medications and supplies. Unfortunately, the system has suffered unexpected, complete system failures rendering the clinician unable to obtain any medications or even medical supplies (e.g., endotracheal tube). In my opinion, this system is inherently dangerous. Hospital pharmacists and manufacturer representatives have cited new JCAHO policy as a justification for their system. In my opinion, these JCAHO-initiated attempts to secure medications in the OR environment may prevent good medical care and should be systematically investigated. I ask that the APSF devote sufficient resources to investigate these developments and interact with governmental organizations to protect patient safety.

Daniel Yousif, MD
Elmhurst, IL