DR.
OM PARKASH EYE INSTITUTE
AMRITSAR
CODE BLUE MOCK DRILL CHECKLIST
Date: ………………………. Location:
…………………………………………………………
Time of announcement of Code: ………………………….
Time of Response of Team: …………………………….
Description of the Incident:
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[Link]. CHECK POINTS REMARKS & FINDINGS
1 Was Code Blue announced loudly and
clearly?
Patient checked for responsiveness
2
and breathing?
Did the Code Blue Team reached on
3
time? ( within 1 min)
4 Did team bring crash cart?
5 Time when CPR started
6 CPR performed correctly?
7 Time of defibrillator arrival at scene
Clothing removed and electrodes
8
placed properly?
Defibrillator voice prompts followed
9
(viz. don not touch patient)
10 Patient placed in recovery position?
11 Patient monitoring continued?
[Link] PARKASH EYE INSTITUTE
AMRITSAR
12 Documented emergency procedure
followed?
13 Shock within 3 minutes Excellent
14 Shock within 5 minutes Fair
15 Shock after 5 minutes Poor
Members of Code Blue team present:
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
Variations/Discrepancies observed:
……………………………………………………………………………………………………………………….……………………………
…………………………………………………………………………………………………………………………………………………….
Suggestions for improvement:
……………………………………………………………………………………………..................………………………………………
…………………………………………………………………………………………………………………………….………………………
Signature of Observer: Verification by Authorized Signatory
[Link] PARKASH EYE INSTITUTE
AMRITSAR
CODE RED MOCK DRILL CHECKLIST
Date: ………………………. Location: …………………………………………………………
Time of announcement of Code: ………………………….
Time of Response of Team: …………………………….
Description of the Incident:
……………………………………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………………………………………
CHECK POINTS REMARKS & FINDINGS
PRE-DRILL ASSESSMENT
Evacuation signs are in good condition YES NO
Exits are clearly marked YES NO
Exit doors operating properly YES NO
Exit routes free from obstructions YES NO
COMMUNICATION & FIRE ALARM SYSTEM
Is drill announced two times? YES NO
Code Red team notified YES NO
Called for emergency fire number (555) YES NO
Was the sound of PA system audible? YES NO
Team members arrived with fire fighting equipments or not? YES NO
FIRE CONTAINMENT
Rooms checked prior to closing doors. YES NO
Doors left unlocked YES NO
Fire extinguishers taken to location of fire YES NO
EVACUATION
All occupants/ patients evacuated successfully YES NO
Evacuation was orderly YES NO
Elevators were used during evacuation YES NO
[Link] PARKASH EYE INSTITUTE
AMRITSAR
UTILITIS
Electrical appliances were turned off YES NO
Lights were turned off YES NO
HVAC units were shut-down YES NO
PLAN
Evacuation performed according to plan YES NO
Occupants reach to safe area away from building YES NO
Fire drill/response team responded according to plan YES NO
Number of occupants evacuated:
PATIENTS……………………… VISITORS…………………….. STAFF…………………………….TOTAL……………………………
Members of Red team present:
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
Variations/Discrepancies observed:
……………………………………………………………………………………………………………………….……………………………
…………………………………………………………………………………………………………………………………………………….
Suggestions for improvement:
……………………………………………………………………………………………..................………………………………………
…………………………………………………………………………………………………………………………….………………………
Signature of Observer: Verification by Authorized Signatory
[Link] PARKASH EYE INSTITUTE
AMRITSAR
CODE YELLOW MOCK DRILL CHECKLIST
Date: ………………………. Location: …………………………………………………………
Time of announcement of Code: ………………………….
Time of Response of Team: …………………………….
Description of the Incident:
……………………………………………………………………………………………………………………………………………………...
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