EMERGENCY CODES vary.
Among Joint Commission-certified
EMERGENCY CODES ARE COLOR-
CODED INDICATORS used in health
care facilities to alert all staff members
of potential issues arising in a facility.
These codes include unique prescribing
criteria for how staff members should
respond to a particular situation, ranging
from an active shooter incident to
cardiac arrest. As a result, specific
statistics are unavailable for many of
these codes. However, some of the
most notable statistics include the
following:
 Active shooter incidents in
hospitals have increased in
frequency of one per month since
2005, reports Brown University.
Across all industries, prevalence
rates have risen 10 percent since
2007.
 Approximately 2,850 fires occur
in health care facilities annually,
asserts the U.S. Fire
Administration.
 Up to 306 cases of infant
abductions took place between
1983 and 2016, most often in
health care facilities.
 In 2016, more than 209,000
individuals suffered a cardiac
arrest, triggering a Code Blue, in
hospitals.
Depending on each facility’s size and
level of care, code designations may
hospitals, most codes maintain industry-
wide designations and similarities.
However, it is important to check with
your local facility administrator or nurse
educator for code designations at the
time of hiring, re-evaluation, and
continuing education. In the interim, you
can use this guide as a refresher of
common code designations and proper
protocols for responding to emergencies
in the health care facility.
A Bit More About
Emergency Codes
Emergency codes help facility personnel
understand how to effectively manage
emergencies. Depending on the type of
facility, emergency codes may be
created by internal administrative
officials or oversight agencies.
For example, the Department of Aging
and Disability Services
(DADS) manages emergency code
support among home and community
support services agencies (HCSSAs) in
Texas, like skilled nursing facilities and
long-term rehabilitation facilities. In
addition, the Centers for Medicare &
Medicaid Services (CMS) provides
additional direction for all provider types
responding to emergencies, particularly
those involving community-based or
facility-based emergency
communication. Training on such
emergencies must be conducted at a
minimum of every 12 months.
Furthermore, health care facilities only
have until November 15, 2017, to draft
and finalize emergency preparedness
administrative plans for responding to
emergencies under new CMS protocols.
Although the new requirements revolve
around administrative protocols, it is
important that health care professionals
understand the primary emergency
codes first.
Code Designations
An active shooter is defined as
an event in which an individual
or group Breakdown of Active
Shooter Prevalence.
Depending on facility preference, Code
Silver or Code Grey may be used
interchangeably. However, Joint
Commission standards were updated in
2010, which advise facility managers to
use Code Silver to denote active
shooter incidents.
During this emergency preparedness
code activation, an overhead
announcement may be made.
For example,
However, some facilities, to prevent an
active shooter incident from worsening,
may have taken an alternative
approach, not using a code and using
plain language only. This may prevent
panic and unnecessary loss of life when
such an incident occurs. In addition, an
announcement may be made to security
personnel and supervisory personnel via
phone, eliminating panic and giving
everyone time to evacuate or shelter in
place.
If an active shooter incident occurs,
follow these steps:
1. Take shelter.
If a landline phone is available, dial
the facility’s active shooter code. For
example, Florida health care
facilities can activate this code by
dialing “20” from a landline phone.
3. Give the call center or emergency
team on the other end of the line
with information about the shooter’s
appearance, hostages, location and
communications. ONLY DO THIS IF
IT IS SAFE FOR YOU TO SPEAK
WITHOUT THE SHOOTER
HEARING OR SEEING YOU.
4. LEAVE THE PHONE “OFF THE
HOOK” TO ALLOW RECORDING
OF ALL EVENTS TAKING PLACE.
 5. If sheltering, stay in place until
instructed to leave by law
enforcement or if the
Code Orange is another code that may
situation permits.
have facility-specific meanings. Joint
6. If the situation is located in
Commission standards define Code
another part of the facility, activate
Orange as an exposure to a hazardous
all security doors to your unit.
material or substance within a facility.
7. If security doors are unavailable,
However, it may be used to denote
barricade the unit with whatever
“attention needed” for violent patient
items are available to prevent entry
situations or other emergencies. The
into your unit.
key lies in understanding a Code
8. When hiding and evacuating are not
Orange’s differentiation from Code
possible, and If your life is in
Silver. A Code Orange may be called if a
imminent danger, try to disrupt and/
patient is being violent during a medical
or incapacitate the shooter by acting
procedure, attempts to leave the facility
aggressive, throwing things at him,
while under an order of protective
yelling or by taking other extreme
custody or another event.
measures.
9. It is important to remember your
Upon activation, an announcement may
duties to protect the lives of those
be made.
you serve during this incident.
10. When leaving the facility or upon For example,
being located by law enforcement,
make sure your hands are up and
away from your pockets and clearly
visible. Depending on your facility’s emergency
preparedness plans, the first example
Following a Code Silver, asserts may follow decontamination protocols,
the Department of Homeland Security including mobile showers, hazmat suits
(DHS), your supervisor may require all or evacuations if necessary.
staff members to complete an incident
report. This may be required even for The second example may have
floors or units where sheltering in place specific guidelines, such as the
was used and no loss of life occurred. following:
Such reports can help managerial staff
learn from the incident and prepare for 1. Upon activation, all proper, trained
the possibility of a future attack. personnel may be called to the
location of the violent patient.
Depending on the facility, proper
 personnel may include those with
training in handling aggressive
patients, like Satori Alternatives to
Managing Aggression.
2. Discuss the specific needs and
issues occurring during the event.
3. Use communication-based
aggression-management techniques
to resolve the situation.
4. If a court order exists, nursing
personnel may be required to
forcibly administer intravenous
medications, apply restraints or take
other specific actions.
5. Complete an incident report upon
the event’s end.
6. Follow up with your supervisor
regarding your actions during the
event, including reviewing proper
protocols and best practices for
responding to such events in the
future.
A Code Red denotes the
presence or reasonable
presumption a fire is occurring
in a facility. For instance, a
staff member who sees or smells smoke
may activate fire codes. In most
facilities, automatic fire detection
systems may alert staff members first.
An overhead code may be called as
well.
For example,
The code may also provide additional
directions when appropriate, like
“Evacuations underway in Medical ICU.”
Some facilities may also provide
additional evacuation codes when
calling the code. “Code Red, Medical
ICU. Code White Medical ICU.” (Code
White will be discussed in further detail
later in this article.)
There are four steps to responding to
a Code Red in a healthcare facility,
given the acronym, RACE, which
include the following:
1. Rescue – Rescue all individuals,
including staff, patients or visitors,
nearest the fire. Do not get
belongings, and only bring items that
are essential. For example, a person
on life-sustaining IVs or machinery
may be moved with patients. Do not
worry about non-life-sustaining items
or equipment.
2. Alarm – Activate the fire alarm if a
code has not yet been called. Upon
activation, some announcements
may be automatic. If an
announcement is not made, have a
staff member dial the overhead
operator or make the
announcement, depending on your
facility’s protocols. Smaller facilities
may allow any staff member to make
overhead announcements.
3. Confine – Attempt to confine the fire
by closing doors between you and
the fire. This will also help prevent
the fire from growing. Additionally,
avoid moving between fire-barrier
doors and areas unless absolutely
necessary. Touch the door prior to
 entering the facility to ensure you
are not walking into an inferno.
4. Extinguish – Using an appropriate
fire extinguisher, attempt to
extinguish the fire.
Fire extinguishers also have an acronym
for remembering how to use the device
and effectively put out the fire, explains
the Occupational Safety and Health
Administration, PASS:
If flames reignite, repeat the process
starting with aiming for the base.
In health care facilities, each floor may
assign one staff member to go help fight
a fire. This staff member should take a
fire extinguisher to the unit affected. Do
not begin using the “PASS” protocol until
arriving at the location of the fire.
Another factor to consider is the type of
fire extinguisher. Some fire
extinguishers may be classified as
a Type A, B or C. Many modern
extinguishers may have a Type ABC,
allowing for use on any type of fire.
Provide all necessary medical or
emergency care to those injured during
a Code Red. This may include staff,
patients and visitors alike.
Believe it or not, a Code Brown
is not widely used in health
care facilities regarding bowel
movements. Although, some
facilities may use as a
non-emergent indicator of bowel
movements.
Most facilities use to
denote severe weather impacting the
facility. Severe weather is defined by
any weather event in which reasonable
damage and possible injury if exposed
to the storm could occur. In other words,
storms with golf ball-sized hail, winds in
excess of 60 mph, tornadoes and
severe lighting are considered indicators
of severe storms. Additionally, torrential
rain and flooding may call for alerts
under this emergency code.
Depending on the size and location of
your facility, different protocols may exist
for responding to a Code Brown. Each
stage reflects the storm’s perceived
level of severity and protocols to prevent
injury.
 Stage 1 – This is the simplest and
less-intense stage of severe
weather. It may be issued when a
severe weather watch is in effect for
the area. Any type of severe storm
watch, such as a tornado or severe
weather watch, may trigger this level
of code. Upon activation, there may
not be any recommended protocol
besides remaining vigilant over
possible storm development and
organization. However, if you can
see lighting or other signs of severe
weather from patient rooms, it is
best to go ahead and close shades,
blinds or curtains.
 Stage 2 – The second stage is used
when a severe weather warning has
been issued. All blinds, curtains,
shutters or shades should be drawn.
This helps prevent glass or flying
debris from entering and harming a
patient. Avoid having patients bath
during this time as the situation
could grow more dangerous
suddenly.
 Stage 3 – The third stage is the
most severe weather code used in
health care. It denotes an imminent
threat to the facility from severe
weather, like a tornado or hurricane-
force winds in Tornado Alley. Stop
what you are doing, and pay
attention to the details of the severe
weather announcement.
A typical announcement for may
go beyond standard announcements,
advising of expected damage location
and event. For example,
In this case, you will need to prepare
patients and visitors for the event. Ask
all ambulatory patients to leave areas
that will be impacted and go to a safe,
glass-free location, like the stairwell or
interior patient rooms.
Patients in beds that cannot be removed
will need to have the bed’s position
changed to have the head of the bed
raised to its highest position and point
the foot of the bed away from the
windows. This will provide a shield
against flying debris if the windows
break. Give patients, visitors, and other
staff members items, like blankets,
pillows or books to help guard their
faces and heads against possible
debris.
There may be severe weather events
that require a greater response,
including evacuation and relocation to a
safer facility before and after a major
weather event occurs.
Remember to protect yourself if a
tornado or other major event directly hits
your facility using the tips and advice in
this section.
If evacuation is necessary, follow the
protocols and steps set forth
under
Code Pink denotes a missing
child in health care facilities.
However, Code Purple may be
used in conjunction with Code Pink to
provide additional direction and
information regarding an abduction.
For instance, Code Pink may be used
for infants up to six months of age, and
Code Purple for all children older than
six months.
A standard announcement for Code
Pink should include the child’s age,
location and other key characteristics.
The description should be detailed
enough to give most employees, visitors
and even other patients the primary
means of identifying a person in the
facility.
Many facilities have implemented strict
protocols for preventing infant or child
abductions, including limiting access to
units where children are located, using
electronic ankle and wrist monitors for
children’s whereabouts and electronic,
employee-activated entryways.
If a is activated, follow
these steps:
Recognize that the individual is
statistically more likely to be a
female of childbearing age and
possibly overweight, reports
the Hospital Association of Southern
California.
2. Check all assigned patient rooms,
staff areas and hallways of your unit
for the suspected abductor and
child.
3. Require anyone matching the
description to please remove
oversized clothing, like heavy
jackets to check for the missing
child.
4. In addition, notify security of any
person matching the description
prior to confronting the individual.
5. Use any means necessary, without
putting yourself or the presumed
person of interest at risk for violence
or injury, to prevent the individual
from leaving the facility.
6. Call for help if an individual is
actively trying to leave a facility with
a child during a Code Pink.
7. All external doors should be locked
upon activation of a Code Pink, and
no one should be allowed to leave
the facility.
 8. After locating the child and removing
the child from the abductor’s
custody, follow up with your
supervisor regarding ways to
improve protocols and practices if a
future event were to occur.
9. Only allow individuals to leave the
facility upon clearing the Code Pink.
 Teach parents about proper
procedures for preventing an
abduction. While this may seem
irrelevant, parents and guardians
may be the most likely to identify a
suspicious person, behavior or
incident before staff members
activate a Code Pink.

There are a few other ways to help Incidents involving child abduction may
prevent a Code Pink, which include the worsen in hostage situations or
following: incidents involving an active shooter.
Follow your facility’s policies and
 Make sure you know who is on procedures for addressing each code in
the floor. When parents or family tandem.
members visit children or infants,
request photo identification to
prevent unauthorized entry to the
unit.
A Code Black denotes a bomb
 Check all children and parents for
threat to the facility. This may
proper documentation and safety
include the identification of an
equipment, like patient-parent
actual bomb within the facility. To
matching armbands or electronic
prevent confusion, always consider any
monitors, to prevent an abductor
Code Black to be a verified threat to the
from taking a child.
facility.
 Report any malfunction of child-
If a threat is phoned to the facility, try to
safety equipment, especially
get as much information about the caller
problems with abduction locks and
as possible. If the phone has a record
monitors, at once.
function, activate it without notifying the
 Report any suspicious behavior
other party on the line. Ask questions
to security or appropriate
about the threat, and signal the issue to
personnel. This tip may be most
other employees to activate the Code.
used when parents have
Try to keep the caller on the line for as
disagreements or court orders
long as possible. Ask these questions:
limiting contact with children. In
some cases, a child’s own parents
 Where is the bomb located?
may attempt an abduction if a court
 How soon will it detonate?
order has removed custody from the
 Why has a bomb been placed in the
parents.
facility?
  How do you know a bomb is there?
 When was it placed?
 What do you want in exchange?
 What is your name?
 Do you have a contact number to
call you back on?
 Can you tell me anything else about
the bomb?
It is important that you remain calm and
not get angry at the individual phoning in
a threat. Upon the arrival of security or
law enforcement, turn the call over to
them.
Depending on your facility, an overhead
announcement will be made.
For additional guidance, the DHS Office
for Bombing Prevention and the FBI
have created a checklist for determining
the credibility of a bomb threat.
A low-risk threat has the following
characteristics:
 The threat is vague.
 Information is inconsistent, lackluster
in detail or implausible.
 The caller is easily identified and has
made multiple calls.
 The threat was discovered, like
finding a package, not receiving an
actual threat.
Medium-risk threats may have the
following characteristics:
 A direct threat is feasible.
 Wording that indicates the
perpetrator has a possible plan for
the bomb or threat.
 Indications of a time and place for
the bomb to detonate.
 A lack of strong indicators that the
person has taken preparation steps
for completing the treat.
 Indications of the bomb’s
composition.
 The increased emotional state of the
perpetrator, like saying, “I’m
serious,” or “I’m going to do this.”
High-risk threats are very specific and
realistic. The perpetrator may give
names, reasons for why he or she is
doing this, information about plans to
detonate the bomb, including actions
taken to ensure its completion, like
taking a hostage or using weapons to
protect the bomb. In addition, the
perpetrator may provide his or her own
identity.
Some medium-risk threats and all high-
risk situations require immediate
intervention. If law enforcement and
security professionals have arrived,
follow their commands. Otherwise, you
need to activate the code denoting an
evacuation due to a bomb threat. In this
case, the overhead announcement may
include a double-code for both a bomb
threat and evacuation (Code White),
depending on your facility’s protocols.
Furthermore, the areas being evacuated
should be listed.
Follow these steps in the interim:
 1. Remove yourself and any individuals
in imminent danger from a
suspected bomb or package. This
includes evacuating the floor or unit
if the bomb is located in your unit.
2. Contact authorities as soon as
possible, and active the Code Black.
3. Depending on your facility and the
care-level required of your patients,
you may need to begin evacuation
procedures.
4. Unlike Code Silver, do not shelter in
place. Begin evacuating the facility,
starting with a reverse-triage
protocol. (More on reverse-triage
protocols will be discussed under
“Code White.”)
5. If the threat not found to be credible
by law enforcement, an evacuation
order may be rescinded.
6. Law enforcement personnel or
administration are usually the
individuals ordering an evacuation.
Code White denotes a
mandatory hospital
evacuation. However, it may
not necessarily require a hospital-wide
evacuation. In other words, specific
floors and areas may be evacuated to
improve safety and address the
emergency. The announcement may be
as follows:
Since a
Code White typically involves another
emergency in the facility, additional
codes will be called to indicate the
reason for the evacuation, assuming an
existing code has not yet been
activated.
If a previous code has been
called, like a Code Silver, the overhead
announcement will not likely contain a
repeat of the Code Silver. The key to
understanding how to respond to an
evacuation lies in listening carefully to
the announcements.
When an evacuation code is activated,
you will need to remove as many
patients as possible, including their
family members, from the affected
areas. While you may want to save as
many lives as possible, it is important to
consider your own safety too. Do not put
yourself in a life-threatening situation
unless absolutely necessary.
To evacuate patients, follow a
This protocol is named
because unlike triage, you want to move
the least-intensive patients first. A
standard Reverse-Triage Protocol is
as follows:
1. Evacuate ambulatory patients.
2. Remove wheelchair-bound patients.
3. Remove bed-bound patients. If
elevators are not function, like during
a “Code Red,” drag the patient’s bed
with the patient still in bed down the
stairs. However, be as careful as
possible for patients that have
 recently undergone surgery or major
medical procedures.
4. Patients in the middle of medical
procedures should be moved as
soon as it is reasonably safe to do
so. If the procedure is wound
dressing or other minor procedure,
stop, cover the wound and begin
respective evacuation protocols.
5. If patient family members are
present, ask them to please help
with getting their loved ones out of
the facility.
A Code Green is another
emergency code used in
health care facilities to denote
the activation of the emergency
operations plan. This plan may comprise
any of the aforementioned emergency
codes and the facility’s immediate
command centers. Furthermore, a Code
Green may be used explicitly for
denoting an external emergency in the
community or area, like a terrorist attack
or a mass shooting.
The processes and steps to respond to
a Code Green tend to involve multiple
protocols across all emergency codes.
In addition, new CMS guidelines have
been released providing additional
direction on why Emergency Operations
Plan Activation is necessary and how
facilities must prepare for these events.
As a nurse or other immediate
caregiver, your facility will provide
additional direction on what you need to
accomplish and complete with respect
to training for new changes in plan
activation. Due to the intensive,
administrative-driven protocols that must
be reviewed and managed in creating
an Emergency Operations Plan, the
next journal will focus on an in-depth
discussion of Code Green and
Emergency Preparedness and
Operations Planning.
In the interim, follow the commands
given by your facility managers and
administrators when activating a Code
Green.
Code Blue is among the most
easily recognized emergency
codes in existence. While most
associate it with the cardiac arrest of a
patient, it may be used to denote any
medical emergency in a health care
facility, including medical emergencies
involving patient family members.
Upon activation of a Code Blue, listen to
the announcement for location.
Depending on your facility, all available
staff members from floors adjacent to
the affected floor may be called to assist
with the code.
Your immediate actions if a code occurs What Now?
on your floor should be assigned upon
reporting for duty. Every emergency code used is only as
effective as the staff members’
For example, the Charge Nurse may understanding of their proper response
assign individual staff members to and responsibilities when a code is
perform compressions, manage airway, activated. If you need any direction on
document, activate overhead these codes, ask for a supervisor for
announcements, draw labs and give additional information and training
medications. materials. In addition, now is an
excellent time to get out your CPR, BLS,
If you do not have an assignment for
ACLS or PALS cards, and check the
codes at the start of a shift, ask the
expiration dates.
Charge Nurse about it. He or she may
have forgotten to create assignments for Know what to do if an emergency code
a code. In addition, your facility may is called in your facility, and update your
have an “anyone jump in” policy. This training if any certification will be
means that the first person to get to the expiring within the next three months.
scene will begin with CPR, and all By taking action today, you can be ready
subsequent individuals will “jump in” to for the emergencies that tomorrow’s day
help. in the life of a health care professional
will bring.
It is also important to ensure you have
the appropriate credentials for
responding during a Code Blue. This
may include Advanced Cardiac Life
Support (ACLS), Pediatric Advanced
Life Support (PALS), Basic Life Support
(BLS) and CPR & First Aid training.
Training for each type of emergency
certification is typically good for two
years. However, your individual state or
facility may have additional guidelines
for completing training more often. For
example, nurses in critical-care facilities
may be needed to renew certifications
annually or complete continuing
educational units throughout the year.