The document outlines safety protocols ("codes") for different emergency situations in a hospital setting. It describes codes for fire (Code Red), medical emergencies like cardiac arrest (Code Blue), violent patients (Code Violet), missing children (Code Pink), bomb threats (Code Black), and provides guidance on roles, procedures, and equipment for responding to each code.

1. Codes in Hospital
Safety measures

2. Codes
• Protocols for peculiar situations happening in and out of Hospital
• To Activate concerned persons without creating chaos
• Training and providing infrastructure are pre requisites
• Team Building and Mock drills and Audit of Drills
• Corrective and Preventive Actions (CAPA)
• Public Address System – Announce three times with Location e.g
• Code Red first floor Lecture hall
• Code Red first floor Lecture hall
• Code Red first floor Lecture hall

3. Codes
• Code Red – Fire
• Code Blue – Cardiac Arrest
• Code Pink – Child Abduction
• Code Black – Bomb
• Code Violet – Violent Patient/ Attendant
• Central Unified number for CODES

4. Code Red

5. Code Red
• R - Rescue
Move patients and assist visitors or impaired employees away
from immediate danger of fire or smoke
• A - Alert others
Activate manual pull station alarm as soon as possible. Call #7777
and state the location, type of fire and size.
• C - Confine
Close all doors and windows. Pack sheets and towels under doors
to contain smoke.

6. RACE
If there is oxygen in the area:
• Stop local supply
• Whole hospital supply shut off only by the order of Fire Safety Officer
• E - Extinguish
Select the appropriate fire extinguisher. Use the P-A-S-S technique to
extinguisher the fire.
• E - Evacuate
Move people (patients, parents, visitors, staff) to the evacuation area.
Stay in the evacuation area until ordered to move by the Fire Marshal.
Staff on floors above the fire use fire exit stairwells to evacuate.
• Close doors behind you.

7. Classes of Fire and Type of Extinguishers

8. Code Blue – Single Rescuer

9. Code Blue – Two rescuers

10. Code Blue - Infant

11. Code Violet
• Security is notified of the location and nature of the incident, as well as a description of
individuals involved.
• While waiting for assistance, the staff uses every precaution to protect him or her or others from
injury.
• When an individual is actively disruptive, or the potential for disruptive behavior is identified,
staff should:
• Avoid confronting the individual, if possible.
• Excuse him/ her from the area.
• Notify security.
• Meet with the officer away from the individual and provide additional information on the
incident.
• Identify a non-public area where officers may speak with the individual until the situation de-
escalates.
• Responding officers evaluate the situation and may remove individuals from the premises and/or
inform police when necessary.

12. Security‘s role
• Recover the weapon safely/ Isolate the violent person.
• Complete appropriate documentation and notifications, as
determined by the facts of the incident, and resulting actions of the
officers.
• If required inform police
• If possible take photograph in mobile phone or through other means.
• If the person using vehicle, note down the number.
• If the person in violent mood and escaping let him escape but inform
police
• Do not indulge in provocative arguments.

13. Code Pink
• Child abduction
• Security staff trained in swift response
• Lock up Plan
• Public Address System
• Networking among Security Staff
• Attendant education regarding handing over the child to staff only
• ID bands for inpatients
• First responder – Notify central code phone number – specify location, age
and other specifications of child and if known – abductor
colour/name/height/clothes etc.

14. Code Pink
• Operator announces – Code Pink missing from location- every five minutes,
with particulars of child
• Also announce that all patients and families return to their rooms.
• The staff member discovering the missing child should then remain in the
room and secure the area (as it is a crime scene) until hospital security or
Police Department (PD) arrive.
• All witnesses and/or involved personnel should remain at the location until
they are released by the PD. If the event occurs at shift change, no
employees should be allowed to leave the campus.
• In addition to covering the exits and stairwells, any other available staff
should check each room, office, bathroom, closet, etc. All patient
discharges or transfers should be put on hold until the Code Pink is “all
clear.”

15. Response for All Staff
• ALL INDIVIDUALS SHOULD BE STOPPED AND QUESTIONED.
• THE RECOMMENDED APPROACH SHOULD BE AS FOLLOWS:
• Inform people we have a missing child.
• Ask the person “Is this your child?”
• Check the child and/or adult for hospital ID bands. (Parents/legal guardians of inpatient
children are given an ID band to identify them with their child).
• Ask person to open any large bags or purses (if missing child is an infant).
• If the person has a child with them that is a toddler or older, ask the child, “Who is the person
with you?”
• If the person has a child with them that is a toddler or older, ask the child, “What is your
name?”
• Ask the person where they have been in the hospital. If they stutter or can’t remember
where they were, notify Security.

16. Actions to be taken by staff
• If an abductor identified, ask him to come with them to an area
with a phone and call Security.
• At no time should the staff member place themselves in
danger.
• If an employee feels threatened or uncomfortable, let the
person go and notify Security immediately.
• If possible, one employee should contact Security while the
other employee follows the suspect (at a safe distance) to their
vehicle and obtain a description and if possible, a license plate
number.
• Security should respond and attempt to block the vehicle.
• Code Pink all clear upon confirming that the child/infant has been located and
returned.

17. Code Black
• Bomb/ Bomb Threat
• Bomb Threat Checklist
• RECEIPT OF THREAT
A bomb threat shall be known as a Code Black.
In the event a bomb threat is received through a telephone call, the person
receiving the call should:
• Keep calm.
• Obtain a copy of the Bomb Threat Checklist
• Note and write down the extension/phone number of incoming call if displayed.
• Note the time of the call.
• Note exact words of caller, ask when the bomb is due to go off, where it is located, and what
the device looks like. Keep the caller on the phone as long as possible.
• Note description of the voice, age, sex, and any discernible back-ground noise.
• Call code phn number and report the threat.

18. Do’s and Don’ts
• GENERAL RULES WHEN SUSPICIOUS OBJECT FOUND
• In the event a bomb or suspicious condition is found, call Police and notify
Security.
• DO NOT
• Attempt to touch or move a suspicious object
• Remove or permit anyone else to remove materials which may aid in the
investigation of the crime
• NOTIFY
A. Switchboard
• House Supervisor
• Environmental Health and Radiation Safety Staff

19. Further Action
• Authority
• Officer on duty shall assume overall responsibility.
2. UT Police shall confer an immediate evacuation, if patient care area
with the Medical Director, the Chief of Staff, and the Administrator on call
regarding an immediate evacuation.
• EVACUATION
• The safest course of action, the Telephone Services
operator shall announce throughout the affected building: ATTENTION ALL PERSONNEL:
CODE BLACK,____ BUILDING, ____ FLOOR. PLEASE EVACUATE THE BUILDING
IMMEDIATELY. This announcement shall be repeated three (3) times.

20. Evacuation
• Evacuation should progress in sequential stages laterally (in floors above and
below area) then vertically, then to other buildings as necessary.
• The evacuated area shall be isolated and entrance restricted by the Police
Department and members of the search team.
• Should vertical evacuation be necessary the location to which patients will be
taken will be determined based on the situation. This determination shall be
based upon the type of patient involved and locations available.
• Assembly Area