C O D E B L U E
M O HA M ED N A G AT Y
BY REHAM
O F PRO F . D R. EM A N ELSAY ED
UNDER SU P ERVI SI O N
CODE BLUE
• Code blue is a part of an emergency code system.
• used to indicate a patient requiring resuscitation or otherwise in need of immediate medical
attention, most often as the result of a respiratory or cardiac arrest. Each hospital, as a part of a
disaster plan, sets a policy to determine which units provide personnel for code coverage.
• The announcement also tells you where the emergency is.
CODE BLUE INCIDENT REPORT
CODE BLUE INCIDENT REPORT EXAMPLE
• a family with three children is visiting their grandmother who is an ICU patient.
the mother reports that her twelve-years-old has a bad peanut allergy and was
accidentally given a snack with peanuts. the child’s father comes running to the
nursing desk and tells you to see the child while pointing down towards the end
of the bed. you are the unit supervisor and see the child down the hallway with
pale skin and having significant difficulty breathing then arrested.
CODE BLUE INCIDENT REPORT EXAMPLE
• Date: 17/3/2024
• Time: 1 pm
• Location: ICU
• Patient: S. F. A.
• Code blue incident description: twelve-years-old child has a bad peanut allergy and was
accidentally given a snack with peanuts. The child fall down the hallway with pale skin and having
significant difficulty breathing then arrested, the staff activated a code blue. The team arrived after
30 sec and started ACLS protocols
CODE BLUE INCIDENT REPORT EXAMPLE
• Resuscitation efforts: CPR initiated for 1 min then ROSC achieved, epinephrine
was given, immediate intubation was done
• Resuscitation outcome: Recovery: the patient regained heart rhythm and admitted
in the ICU for further treatment
INCIDENT REPORT
It is a system of reporting patient safety incidents that happen in healthcare,
investigate or review why the incident happen, learn from the incident, take
appropriate action to prevent similar incident from happening and share with
others.
INCIDENT REPORT
INCIDENT REPORT EXAMPLE
• Date: 18/3/2024
• Time: 11 am
• Location: internal medicine ward/ room 508
• Patient name: S. M. M.
• Medical record number: 00226439AAL
• Description of incident: a medication error occurred when the nurse administered vancomycin to the patient. The prescribed dose was
correct, but the rate was half an hour instead of one hour. The incident was discovered at 11 am when the patient experienced rash on the
upper extremities
• Action taken:
• The nurse immediately informed the charge nurse and physician
• Avil and dexa were given to the patient, then the rate was slowed to over two hours
• Incident reported to pharmacy for review & documentation
• Family informed of the error
• RCA conducted to prevent future occurrence
CUSP TOOL: CULTURE CHECK-UP PROCESS
• the comprehensive unit-based safety program (cusp) is a method
that can help clinical teams make care safer by combining
improved teamwork, clinical best practices, and the science of
safety
CUSP SUPPORTS
KOTTER’S EIGHT STEPS OF CHANGE
Kotter CUSP Toolkit Modules
Step 1: Create a sense Understand the Science of Safety
of urgency
Step 2: Create a guiding Assemble the Team
coalition Engage the Senior Executive
Step 3: Develop a shared Identify Defects Through Sensemaking
vision
Step 4: Communicate the Understand the Science of Safety
vision Identify Defects Through Sensemaking
CUSP Supports
Kotter’s Eight Steps of Change
Kotter CUSP Toolkit Modules
Step 5: Empower others Assemble the Team
to act Identify Defects Through Sensemaking
Implement Teamwork and Communication
Step 6: Generate short Implement Teamwork and Communication
term wins
Step 7: Consolidate Identify Defects Through Sensemaking
gains and produce more
change
Step 8: Anchor new Understand the Science of Safety
approaches in culture Implement Teamwork and Communication
TOOLKIT MODULES
LEARN ABOUT CUSP
ASSEMBLE THE TEAM
ENGAGE THE SENIOR EXECUTIVE
UNDERSTAND THE SCIENCE OF SAFETY
IDENTIFY DEFECTS THROUGH SENSEMAKING
IMPLEMENT TEAMWORK AND COMMUNICATION
APPLY CUSP
TOOLKIT USERS
SENIOR EXECUTIVES
PATIENT SAFETY OFFICERS
NURSE MANAGERS
FRONTLINE STAFF
PHYSICIAN CHAMPIONS
THA N K Y O U !