Improving medication management through the redesign of the hospital code cart medication drawer

Justin B. Rousek, M. Susan Hallbeck

Research output: Contribution to journalArticlepeer-review

23 Scopus citations


Objective: This study utilized usability testing and human factors engineering (HFE) principles to create efficient code cart medication drawer modifications to improve code blue medical emergency (code) medication management.Background: Effective access to medications during a code is a key component in delivering optimal care and has been found to be a major problem among health care organizations; however, little research has been conducted to improve the efficiency of medication management during a code.Method: A total of 26 health care professionals (13 pharmacists and 13 nurses) were asked to locate items within a code cart medication drawer during two independent simulated code scenarios alternately using either a baseline medication drawer (control; Drawer 1) or a prototype medication drawer (prototype; Drawer 2), which was developed using HFE principles and usability testing. Overall medication retrieval time, wasteful actions, and survey responses were recorded.Results: Drawer 2 had significantly faster trial completion times (p =.005) and fewer wasteful actions (p <.001) compared to Drawer 1. Participant survey results rated Drawer 2 (prototype) significantly higher (more favorable) for medication drawer visibility (p <.001), usability (p =.011), and organization (p <.001) compared to Drawer 1 (baseline).Conclusion: The HFE redesign concepts incorporated into Drawer 2 (consisting of visibility, grouping, and organization) produced successful, low-cost, and generalizable modifications that can improve patient care.Application: The findings demonstrate that HFE and usability applied to code cart design are effective, are customizable, and can affect patient safety by saving valuable time and reducing wasted motions (including errors) during code situations.

Original languageEnglish (US)
Pages (from-to)626-636
Number of pages11
JournalHuman Factors
Issue number6
StatePublished - Dec 1 2011


  • code cart
  • health care
  • human factors engineering
  • medical emergency
  • usability

ASJC Scopus subject areas

  • Human Factors and Ergonomics
  • Applied Psychology
  • Behavioral Neuroscience


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