KINGDOM OF SAUDI ARABIA

MINISTRY OF HEALTH
DIRECTORATE OF HEALTH AFFAIRS RIYADH
HAWTAT BANI TAMIM GENERAL HOSPITAL

PHARMACY DEPARTMENT
CRASH CART OPENING FORM

Patient Name: .............................................................................

MR No: ............................................. Unit: Labour and Delivery Ward.

Time Crash Cart Opened: ..................................

SR. Initial Balance

Drug Description Notes
No. Stock Qty.
1 Atropine Sulphate 0.5 mg / mL Injection 20
2 Adrenaline 1 mg / mL Injection 20
3 Sodium Bicarbonate 8.4 % Injection 2
4 Dextrose 50 % Injection 2
5 Dopamine 200 mg / 5 mL Injection 4
6 Dobutamine 250 mg / 5 mL Injection 4
7 Amiodarone 150 mg / 3 mL Injection 3
8 Nitroglycerine 50 mg / 10 mL Injection 3
9 Adenosine 6 mg / 2 mL Injection 4
10 Lidocaine 2 % Injection 2
11 Aminophylline 250 mg / 10 mL Injection 4
12 Dihydralazine / Hydralazine Injection 3
13 Hydrocortisone 100 mg / Injection 4
14 Furosemide 20 mg / 2 mL Injection 5
15 Calcium Chloride 10 % Injection 5
16 Verapamil 5 mg / 2 mL Injection 4
17 Dexamethasone 8 mg / 2 mL Injection 5
18 Potassium Chloride 20 mEq Injection 4
19 Naloxone 0.4 mg / 2 mL Injection 3
20 Digoxin 0.5 mg / 2 mL Injection 3
21 Metoprolol 5 mg / 5 mL Injection 3
22 Labetalol HCl 200 mg / 20 mL Injection 2
23 Noradrenaline 4 mg / 4 mL Injection 5
24 Lidocaine 2 g + Dextrose 5 % in 500 mL 1

Reported By (Nurse):____________________________

Sign & Date: ____________________________

PH/form no. 1 crash cart exchange replenishment