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Patient Safety Tip of the Week

February 14, 2023

Code Terminology Still Problematic



In our September 18, 2007 Patient Safety Tip of the Week “Wristbands: The Color-Coded Conundrum” we noted the lack of standardization of color-coding of wristbands was problematic. Problems may arise when a healthcare worker who usually works at another facility is now exposed to a colored wristband at a new facility that has a different meaning.


The same problem can occur with the nomenclature of emergency “codes”. In our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a good piece of advice from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). Again, that is because a “Code Yellow” may mean one thing at one hospital and a different thing at another hospital.


So, are we doing any better? Apparently not, according to a new study. Harris et al (Harris 2022) sought to assess the ability of clinical and non-clinical employees across the State of Georgia to correctly identify their facility’s emergency codes.


Anonymous electronic surveys asked 304 employees at 5 facilities to identify the codes for 14 different emergencies. Participants correctly identified the emergency codes with only 44.37% accuracy on average. Codes for fire, infant abduction, and cardiac arrest were most commonly identified correctly (≥90%). Codes for hostage situation, internal disaster, pediatric emergency, and mass casualty incident were incorrectly identified by more than 85% of participants.


They also sought to identify significant predictors of emergency code identification accuracy. Code identification accuracy was significantly higher in participants who received training at employee orientation, had knowledge of emergency code activation procedures, and had worked at their current facility for two to five years. However, accuracy was lower in employees who had worked at four to five facilities in their careers, suggesting that code confusion becomes particularly pronounced after having more than three healthcare employers.


They also assessed employees’ opinions of emergency alert systems. Most survey participants favored a color-code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors, and of maintaining confidentiality and discretion. But, obviously, the color-code-based systems are not cutting it. Most code systems in the US use color-based codes (e.g., “Code Red” for a fire), predicated on the idea that colors are easier to remember and serve as a tool to increase encoding among a target audience. But individuals often associate specific colors with specific images that may not be universal.


Harris et al. point out that approximately one in five healthcare workers has at least two jobs, and each employer may have its own emergency code designations. Moreover, staffing issues have resulted in many new or temporary healthcare workers at any facility, particularly since the COVID-19 era began.


Hospital associations in more than 25 states in the US have recommended the introduction of a standardized set of emergency codes and multiple hospital associations have advocated using “plain language” codes (Wallace 2015).


There is currently no national standard in the United States for such warning systems in healthcare facilities. Harris et al. conclude that transitioning to plain language overhead emergency alerts will better position employees, as well as patients and visitors, to effectively respond to emergencies and disasters occurring within a healthcare facility. They note that both the U.S. Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services (DHHS) advocate for plain language communications in all emergency and disaster communications.


The commonly cited reasons against plain language-based alerts are fear of causing panic in patients and visitors, and of maintaining confidentiality and discretion. We’ll counter that by noting that patients and visitors can play an important role in resolution of the incident leading to the alert. They might not know what a “Code Gray” or “Code Pink” means, but they could certainly help identify a wandering patient or abducted infant if the alert was more specific.


The Harris study showed that both clinical and non-clinical employees have limited accuracy in identifying their hospital’s emergency codes. Code identification accuracy was significantly associated with training at orientation, knowledge of emergency code activation procedures, facility experience, and total facilities in the career. The majority of survey participants favored a code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors and maintaining confidentiality and discretion. The Harris study and the Wallace study cite several other studies demonstrating “code confusion”.


Hasn’t the time come for standardization of emergency alerts in healthcare? While the time-honored use of colors in naming codes could be standardized, we strongly favor transition to plain language-based alerts.






MHA (Minnesota Hospital Association). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011



Harris C, Zerylnick J, McCarthy K, et al. Breaking the Code: Considerations for Effectively Disseminating Mass Notifications in Healthcare Settings. Int J Environ Res Public Health 2022; 19(18): 11802



Wallace SC, Finley E. Standardized Emergency Codes May Minimize “Code Confusion”. Pa Patient Saf Advis 2015; 12(1): 1-6





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