Save Millions in Litigation Costs with Code Blue Documentation

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Code Blue Legal Issues


At some point, every medical professional will wonder about the legal ramifications of an in-hospital cardiac arrest (code blue). Code blue events happen quickly, and documenting the entire occurrence may be difficult. Unfortunately, if the documentation doesn’t exist, it isn’t easy to prove that the team provided adequate care. Lawsuits are uncommon, but the risk is considerable. When patient outcomes are unfavorable, that risk increases. Patients experiencing in-hospital cardiac arrest are often already in fragile condition. The percentage of patients who survive to discharge is surprisingly low (only 17% – 20%, according to the Society of Hospital Medicine¹). When a code blue does have a negative outcome, the patient’s family may find comfort in the documented proof that the highest quality care was provided. An accurate documentation of timing is crucial. It’s important to know when each dosage is administered and when the next should occur. Usually, the documenter also keeps time. The following list includes critical timing elements:
  1. Epinephrine should be delivered at 3-5 minute intervals.
  2. The person providing compressions should be rotated every two minutes to ensure that the patient receives adequate CPR.
  3. Defibrillation shocks should be delivered every 2 minutes.
  4. Compressions may be frequently paused to take vitals, administer defibrillatory shocks, and facilitate endotracheal intubations when managing patients with difficult airways. However, compressions should never be paused for longer than 10 seconds.
Ensuring these elements are accurately represented in the record establishes the essential proof of care.

HIPAA Compliance

It is also essential to ensure that the record makes it where it needs to go. Even a thorough document won’t improve your organization’s legal standing if no one can find it. Approximately 30% of code blue paper charts are lost before they are transcribed into an EMR. Any event in which a medical record containing sensitive patient information disappears constitutes a HIPAA violation. The code blue record also contains pressing information for the intensive care providers who accept the patient after the event. The documentation needs to follow the patient as quickly as possible, or your facility may not be providing adequate patient care.

The Signature

This is an item that is frequently overlooked. The code leader must sign the code blue record. Without that signature, any medication administered during the code blue event was given without a prescription. This constitutes its legal issue. The signature also provides anyone who views the document with proof that the event was overseen by a trained professional. This is especially necessary during code blue events because cardiac arrest situations tend to be chaotic. It’s far too easy for a dosage to be poorly timed or missed completely without a practiced, guiding hand.


Improving code blue documentation can occur at both a personal and organizational level. Personal performance can be improved by enhancing your documentation skills, familiarizing yourself with the code blue sheet at your hospital, and practicing whenever possible (preferably in a simulated code). At an organizational level, the code blue documentation sheet can be altered and optimized, or the organization can switch to an electronic documentation method (such as a tablet-based solution). It’s also possible to modify the handling of code blue situations to better suit the organization’s needs.

Changing the Documentation Method

Changing the documentation method is generally done at an organizational level. If your organization uses paper documentation, refining that recording document to fit best the environment’s flow could improve your code blue records’ quality. Because code blue events are often fast-paced, the documentation sheet must be as intuitive as possible. It is a good practice to go over the forms with the practicing nurses or code blue team to ensure the form follows the hospital’s code blue protocol as closely as possible. Simulations can be run to refine the document’s layout further. In many cases, an electronic documentation method is a better solution. RevivePro offers built-in timers and standard dosage defaults to help recorders create an accurate record and allow the code leader to keep precise time.
RevivePro also offers immediate upload of the record to be quickly accessed by intensive care after the event. Immediate upload also ensures that the document is immediately available to provide the patient’s family and is directly accessible by risk management. Electronic documentation methods also remove the need to transcribe written records into an EMR. Issues associated with illegible handwriting or lost documents are also avoided.
Brian Ross, PhD, MD

Brian Ross, PhD, MD

Professor Emeritus, Department of Anesthesiology and Pain Medicine, University of Washington