Code Black Procedure

Hill Country Memorial Health System

Fredericksburg, Texas

Originating Department: Environment of Care/Patient Safety Committee

PURPOSE:

To provide employees guidelines for responding to a security emergency that places either themselves or others at risk for injury or harm.

DEFINITIONS:

Code Black - A security emergency when an employee recognizes danger or potential danger to self or other

PROCEDURE:

1. Activation of a Code Black

A. Security emergencies can be communicated via the telephone system by dialing Ext. 200 or Ext. 610.  Pick up the handset and dial the number.  DO NOT HANG UP THE HANDSET until the operator has obtained or monitored needed information.

B. If you are involved in a Code Black situation you can also utilize the overhead paging system to announce the code by dialing 8666 and enunciating Code Black, in a clear and loud voice, and the location every 10 seconds x 6.

C. Security emergency response can also be activated by silent alarms located in the Switchboard, the Emergency Department, and the Central Nurses Station on the second floor.  Activation of these alarms will trigger a response by Law Enforcement.  Once the alarm is activated, the Plant Operations or Switchboard staff must reset the alarm.  

2. Communication

A. Upon notification of a Code Black situation, the switchboard operator will call the Fredericksburg Law Enforcement Dispatcher to notify them of the situation, any information she/he may have and request that the police respond immediately.

B. The switchboard operator will next notify the Patient Care Coordinator (PCC), Administrator on Call (AOC), and the Security Officer.

3. The AOC will make the determination if activation of the Emergency Preparedness Plan is indicated.  (See Emergency Response Plan)

4. Staff Response to Code Black

A. Only the Patient Care Coordinator (PCC) will go to the affected area to assess the nature and extent of the situation.

B. Personnel will, as indicated, evacuate patients and visitors out of the immediate area.  Refer to Evacuation Plan (Code Green) provided in this manual.

C. Employees should not unnecessarily place themselves at risk for harm, and should to the extent possible, comply with any demands until Law Enforcement arrives on the scene.

D. Once Law Enforcement officials arrive on the scene they will assume command of the situation.

E. Personnel need to take note of anything that may be important to any investigation that may take place after the incident is concluded.

F. Do not disturb anything that may be evidence.

G. To maintain patient confidentiality, do not discuss the situation with anyone other than Law Enforcement or hospital administrative representatives.

H. Everyone in the hospital should remain calm and stay in a heightened state of awareness and continue to perform assigned duties unless otherwise instructed.

I. All information that has been collected will be taken to the Conference Room and turned over to Law Enforcement officials.

J. Any witnesses or individuals with pertinent information will report to the Conference Room.

K. The AOC or PCC will be the contact person for Law Enforcement officials.

L. All inquires regarding the event should be directed to the Administrator on Call or his/her designee.

M. After resolution of the situation a Security Incident Report will be completed.  The Director of Human Resources (Security Officer) and/or Quality Management Director will conduct a debriefing with involved individuals to evaluate the response and recognize opportunities for improvement and possible prevention of similar situations.  If indicated, a Root Cause Analysis (RCA) will be conducted as outlined in the Root Cause Analysis Policy in this manual.

N. A summary of the incident and critique will be presented to the Environment of Care/Patient Safety Committee, Quality Council and Board QI Committees at their next scheduled meeting.