Restocking the Code Cart In Dixon v. Taylor, 111 N.C. App. 97, 431 S.E.2d 778 (1993), Dixon had been admitted to the hospital and was diagnosed with pneumonia in her right lung. Dixon's condition began to deteriorate, and she was moved to the intensive care unit (ICU). A code blue was eventually called, signifying that her cardiac and respiratory functions were believed to have ceased. During the code, a decision was made to intubate by inserting an endotracheal tube into Dixon so that she could be given respiratory support by a mechanical ventilator.As Dixon's condition stabilized, Dr. Taylor, Dixon's physician at that time, ordered that she be gradually weaned from the respirator. Blackham, a respiratory therapist employed by the hospital, extubated Dixon at 10:15 p.m. Taylor left Dixon's room to advise her family that she had been extubated.Blackham decided an oxygen mask would provide better oxygen to Dixon but could not locate a mask in the ICU; thus, he left ICU and went across the hall to the critical care unit. When Blackham returned to Dixon's room with the oxygen mask and placed it on Dixon, he realized that she was not breathing properly. Blackham realized that she would have to be reintubated as quickly as possible.A second code was called and Shackleford, a nurse in the cardiac critical care unit, responded to the code. Shackleford recorded on the code sheet that she arrived in Dixon's room at 10:30 p.m. She testified that Blackham said he had too short of a blade and he needed a medium, a Number 4 Macintosh laryngoscope blade, which was not on the code cart. The code cart is a cart equipped with all the medicines, supplies, and instruments needed for a code emergency. The code cart in the ICU had not been restocked after the first code that morning; thus, Shackleford was sent to obtain the needed blade from the critical care unit across the hall. When Shackleford returned to the ICU, the blade was passed to Taylor, who had responded to the code and was attempting to reintubate Dixon. After receiving the blade, Taylor was able to quickly intubate Dixon. Dixon was placed on a ventilator, but she never regained consciousness After the family was informed there was no hope that Dixon would recover the use of her brain, the family requested that no extraordinary measures be taken to prolong her life. A medical negligence claim was filed against Taylor and the hospital. The jury found that Taylor was not negligent. Evidence presented at trial established that the hospital's breach of duty in not having the code cart properly restocked resulted in a 3-minute delay in the intubation of Dixon. Reasonable minds could accept from the testimony at trial that the hospital's breach of duty was a cause of Dixon's brain death, without which the injury would not have occurred. Foreseeability on the part of the hospital can be established from the evidence introduced by the plaintiff that the written standards for the hospital require every code cart be stocked with a Number 4 Maclntosh blade. This evidence permits a reasonable inference that the hospital should have foreseen that the failure to have the code cart stocked with the blade could lead to critical delays in intubating a patient. Accordingly, there was substantial evidence that the failure to have the code cart stocked with the proper blade was a proximate cause of Dixon's fatal injuries. What steps could be implemented to prevent similar occurrences in the future?