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In the case of Dixon v. Taylor, a 1993 decision from the North Carolina Court of Appeals, the plaintiff was admitted to Watauga Hospital and was diagnosed with pneumonia in her right lung.  Her condition deteriorated and she was transferred to ICU. A Code Blue was called when the patient's cardiac and respiratory functions ceased. The attending physician decided to intubate her and hook her up to a mechanical ventilator. The next day, the physician ordered that the patient gradually be weaned from the respirator.  The patient initially breathed on her own, and the respiratory therapist placed an oxygen mask on the patient to help her breathe.  He then realized she wasn't breathing properly and that she'd have to be reintubated as quickly as possible.  While she was being prepared for reintubation, the patient's heart stopped and a second Code was called. 


The Code Nurse recorded everything being done, exactly as it was being done.  The Code Nurse's testimony was crucial at trial.  She testified that upon her arrival in the ICU she saw the respiratory nurse unsuccessfully attempting to reintubate the patient.  She testified further that the respiratory nurse said that he needed a medium, Number 4 Macintosh laryngoscope blade, which was not on the code cart. The code cart had not been restocked since the first Code was called earlier that day, so the Code nurse went to the CCU to get the necessary blade.  Upon receiving the proper blade the doctor was quickly able to reintubate the patient.  However, the patient's heart did not start beating again until 5 minutes after the crisis began.  A neurological examination indicated that the patient was brain dead secondary to suffocation. The patient died of aspiration pneumonia 10 months later, and her estate filed a negligence cause of action against her physician and the hospital.


The jury found the hospital liable in the amount of $900,000 but did not assess liability against the physician in the case. The physician's actions met the standard of care.  Appealing the $900,000 award, the hospital argued that it did not breach a duty of care and that its failure to restock the code cart with laryngoscope blades was not the proximate cause of the patient's death.  However, the Court of Appeals agreed with the trial court.  It ruled that the hospital should have foreseen that failure to have the proper blade could lead to critical delays in intubating a patient. 


The issue of stocking or re-stocking presents itself in countless situations throughout a hospital. Dixon v. Taylor concerns the failure to restock a code cart; however, a case might be brought concerning the failure to restock surgical instruments in an emergency room, or the failure to have a sufficient number of needles available for the administration of intravenous drugs.  In an emergency, the unavailability of certain drugs or equipment that should be readily available raises concerns about the quality of patient care.  It should be noted that the physician in Dixon v. Taylor was not found liable for the unavailability of the appropriate laryngoscopic blade, presumably because it was not his duty to restock the code cart.  He was, nonetheless, named as a defendant in this case.  His care decisions were called into question, and the cost in time, energy and legal fees was considerable.  The implementation of proper procedures should include checks and balances to ensure that necessary equipment is in place during an emergent situation.  Awareness on the part of the entire treatment team of these procedures availability of required supplies, equipment and drugs will increase the likelihood that good quality patient care will be provided.

Patient Harmed by Poorly Stocked Cart

by Attorney Frank E. Reardon

March 1995