Code Cart Tray Redo with Human Factors

ACPE Number: 0204-9999-18-031-L05-P/T
Activity Date: 07/11/2018
Expiration Date: 07/10/2021
Activity Type: Knowledge-based
CE Credits: 1.0 hour, no partial credit
Activity Fee: Free

Activity Overview

The VA team's redesign of medicine trays used in code carts enhanced patient safety through improved accuracy of medication retrieval and increased medication label readability while decreasing retrieval time. In this activity, faculty will highlight concepts of usability testing and how the use of human factors engineering principles can be utilized for medication safety.


The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacist Education as a provider of continuing education.

Target Audience

This continuing pharmacy education is designed for pharmacists and pharmacy technicians to explore the use of a redesigned code cart in reducing medication selection errors.

Schedule of Educational Activities

  • Description of the medication tray redesign and how the results enhanced patient safety through improved accuracy of medication retrieval.
  • A primer on usability testing.
  • Key takeaways for using human factor engineering principles to optimize medication use and safety.


  • Mary E Burkhardt, M.S., RPh, FASHP, FSMSO, National Pharmacy Executive and Patient Safety Program Manager, VA National Center for Patient Safety, Ann Arbor, MI
  • Valerie Miller, M.S.E., Production System Project Leader, Steelcase Inc, Grand Rapids, MI

Learning Objectives

  • Describe how the code cart redesign improved accuracy of medication retrieval to enhance patient safety.
  • Discuss concepts of usability testing.
  • Identify opportunities to optimize medication use through the use of human factors engineering principles at your practice setting.


In accordance with the ACPE's and ACCME's Standards for Commercial Support, anyone in a position to control the content of the educational activity is required to disclose to the accredited provider their relevant financial relationships. In accordance with these Standards, all potential conflicts of interest have been resolved. An individual has a relevant financial relationship if he or she (or spouse/domestic partner) has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the activity content over which the individual has control.

As defined by ACCME, a commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The Standards for Commercial Support do not consider providers of clinical service directly to patients to be commercial interests. The existence or non-existence of relevant financial relationships will be disclosed to the activity audience. All identified conflicts of interest must be resolved prior to the activity.

  • All planners, presenters, reviewers, and ASHP staff report no financial relationships relevant to this activity.

 Methods and CE Requirements

This activity consists of recordings of faculty slides presentations, active learning activities, discussion, and handouts. Participants must participate in the activity in its entirety to claim continuing pharmacy education credit online at ASHP eLearning Portal. Follow the prompts online to complete the evaluation, claim credit and view the statement of credit immediately after completing the activity.

Per ACPE requirements, CPE credit must be claimed within 60 days of being earned. Claim your CE at Once you have processed and claimed your CE credit, we encourage you to check your NABP eProfile account to verify your credits were transferred successfully before the ACPE 60-day deadline. It is an electronic direct-report process so your credits should appear in your account within a few minutes. After the 60 day deadline, ASHP will no longer be able to report your credit(s) for this activity.