Do your anesthesia providers treat their carts like lockers and just throw everything into and onto them? "Don't just pile stuff in any available corner and drawer," says Barry Cranfill, CRNA, of Southern Crescent Nurse Anesthesia in Newnan, Ga., "because you can't provide vigilant, watchful care if you're scrounging around looking for the stuff that you need." Here's advice for maintaining a neat and orderly cart.

1. Organize with safety in mind
A poorly organized cart is a patient safety risk on wheels. Develop systems for stocking, taking inventory, checking for outdated agents and alerting everyone involved in the process about the risk of someone grabbing the wrong vial.

"Each facility can devise its own system, but all staff, from the anesthesia providers to the stocking clerk to nurses, should participate in the process," says anesthesiologist Adam Dorin, MD, MBA, medical director of the Sharp Grossmont Plaza Surgery Center in San Diego.

This kind of team involvement can reduce the risks of medication errors. Let's say you switch suppliers or distributors without telling the anesthesia team. One day, without notice, new bottles show up in the carts. This could lead to anything from a tech putting the wrong bottle in the wrong drawer to the anesthesiologist feeling around and taking out the wrong agent, says John Dombrowski, MD, director of the Washington Pain Center in Washington, D.C. "The key is to notify the anesthesia provider in the event of a change," he says. Another hint to prevent wrong-medication errors: Use color-coded caps.

To cut his odds of committing errors, Jay Horowitz, CRNA, at Quality Care Anesthesia Corp. in Sarasota, Fla., uses his cart's drawers and dividers to separate the classes of his agents into different groups. "This way, I have the local anesthetics in one area and propofol in its own little area," he says. "It makes it nice and concise and, while you still have to be very careful and check the agents each time, it leads me in the right direction."

When setting up for a case, arrange your syringes in the order that you intend to use them, says Mr. Horowitz. The same goes for devices, he says. He puts medications in the top drawer, airway supplies in the one below that, and syringes and IV starting equipment further down. "It's also nice to have a workspace up top for medication labels and two or three boxes of disposable gloves," he says. Mr. Cranfill offers another way to organize your cart: by process - induction, emergence and emergencies.

2. Standardize your carts
Once you've decided on the best way to organize your carts, arrange all the carts in every room the same way. "You should know that you're getting the same thing in room one as you are in room two," says Mr. Horowitz.

It's crucial that whomever stocks your carts understands this system and your anesthesia providers' preferences by heart. "Meet with the individual who stocks your cart and ask him to be your eyes and ears," says Dr. Dombrowski.

It's not just the anesthesia providers who should have this information, says Mr. Cranfill. "Circulating nurses and technicians should also be thoroughly familiar with the organization and location of items in the anesthesia cart so they can assist in providing equipment and supplies if called upon," he says. "I suggest holding a scavenger hunt for these folks to be sure they know where to find things."

Once you've stocked all of your carts with the same items and in the same manner, develop an annual plan to check what you're stocking and be sure you have the best medicines, the most current treatment modalities and the least expensive options, says Dr. Dorin. "This will ensure that patients are getting the best care, that anesthesiologists and nurse anesthetists have the most ideal medications on hand, and that the facility is able to operate in a cost-effective manner," he says.

3. Clear the clutter
Anesthesia providers are creatures of habit, says Mr. Horowitz, and some are meticulous while others are untidy. Even if you're less than neat, there's no excuse for not being sanitary. Mr. Cranfill says in his time practicing he's seen carts with old towels lying on top, sticky substances lining the bottoms of drawers and rows of outdated medications. To keep his own equipment clean, Mr. Cranfill says he has his techs empty and thoroughly clean his carts four times a year, then check that all the agents haven't expired before restocking the cart. "That keeps the carts safe," he says.

Having a system for drawing items and putting them away can keep your cart from becoming a mess during a procedure, says Dr. Dombrowski. He says he has everything organized on his cart before the patient comes in. After he uses an item that he knows he won't need again, he puts it back on the cart. After the procedure, he cleans off the cart and gets everything he'll need for the next patient ready.

"As you do this, you're planning 30 or 40 minutes in advance," he says. "This keeps clutter down, makes it easy to clean up the area and the station remains organized."

Consider placing rarely used tools like emergency supplies on another cart, says Dr. Dorin, as long as they remain readily accessible.

4. Think security: Lock your carts
For the past few years, there's been an ongoing debate among anesthesia providers and inspectors over how to be sure controlled agents (Schedule II, III, IV and V drugs) can be secured against misuse. Some argue that keeping these agents safe means locking them into the cart, while others balk at how that would make them hard to access in the OR. Earlier this year, Medicare settled things with a new rule that says the drugs don't have to be locked into the cart if the cart is stored in a secure location, meaning a locked room that can only be entered by select personnel.

But even though you don't have to lock your cart, you're better off doing so anyway, says Mr. Cranfill. "I see no reason why a cart shouldn't be locked," he says. "There's stuff in there that can hurt people, and while some inspectors won't mind if it's not locked, you still won't be wrong if it is."

Another advantage to locking your carts, says Dr. Dombrowski, is that even though a cart in a "secured area" may be safe from the public or patients, you still have to worry about other staffers stealing the drugs. "The janitor or the nurse can steal from the cart, and that's a possibility we have to deal with in the real world," he says.

The technology behind locking carts has changed rapidly, says Mr. Cranfill. Instead of locks and keys, some systems feature everything from keypad codes to thumbprint recognition to restrict who can open the drawers. "It's expensive, but considering the problems with narcotics control, it's not a bad idea to consider," he says.

Given that anesthesia providers and pain-management specialists have to deal with lots of drugs that have the potential for abuse, Dr. Dombrowski says facilities may have to develop a solution that is both practical and reasonable for the small quantities of agents you need each day. "We keep our (controlled) drugs on our person at all times," he says. "If there's a miscount, it's that person's responsibility. That way, we don't have to worry about the drugs being left on the cart."

5. Customize for convenience
Now that your carts are organized, standardized, sanitized and secured, it's time to add some of the little touches that make them easier to use. Here are some other tips from our experts that can help you get the most out of your cart:

• Make sure all the compartments are big enough. "The cart should be an inviting workspace in good order, with smoothly operating compartments and proper design for the anesthesia environment," says Mr. Cranfill. "Too many times, 'any old cart' is used and the drawer and compartment sizes aren't conducive to the proper storage and access for anesthesia equipment."
• Try to go stick-free. When stocking your cart, Dr. Dorin recommends making an effort to use needle-less supplies and stick-proof IV catheters - or at least make them available.
• Attach a generic trash receptacle and sharps disposal basket to the sides of the cart. It's convenient, and it's one more thing not cluttering the OR floor, says Mr. Horowitz.
• Cleaning hands should be a snap. Every cart should have antiseptic hand cleanser in place for easier and regular use, says Dr. Dorin.
• Stay out of the dark. Many laparoscopic procedures require you to dim the lights, so be sure there's a light source near your cart, even if it's a spotlight, says Dr. Dombrowski. "However you do it, you should have enough illumination to easily read a label," he says.
• Reserve space for music. "We always have space on the top of the cart for my iPod speakers," says Mr. Horowitz.