HOSPITA NAME AND HOSPITA NAME

CODE BLUE MOCK DRILL OBSERVATION FORM

LOGO

Mock Drill Location:

Date: Time:
S. No. Event Yes/No Time Remarks
1. Mock Drill start time
2. Patient spotted at
3. First responder checks for patient’s responses
4. Code Blue reported by first responder at
5. Code blue team informed
6. CPR initiated at
7. Time of arrival of crash cart
8. Time of arrival of 2nd responder/ Code Blue
Team
9. Call made for cardiac ambulance
10. Staff cordons off the area
11. Staff stops the lift on the floor of event
12. Patient transferred at
13. Transport by lift/vehicle
14. Code Blue deactivated at

Detail of discrepancies observed -

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Sign of Observer:…………………….
Date:………………..