Hospital Wide Safety and Security

Table of Contents



Code Black - Active Shooter Code Triage


Code Blue – Cardio/Pulmonary Arrest


Code Green -  Weather Alert


Code Grey – Bomb Threat


Code Orange – Decontamination


Code Pink - Infant/Child Abduction


Code Red – Fire


Code Triage – Diaster/Diaster Drill


Code White – Pager Outage


I.E.Q. – Indoor Environmental Quality


Medical Emergency: Immediate Procedures


Personal Injury


Radiation Spill



Code Black - Active Shooter

·       When you hear Code Black announced, immediately move to your designated position; leave the building if possible.

·        Stay clear of windows and exposed areas

·        Move to a room with a door and lock yourself in!

·        Notify Security of your location (Extension 1-4787, or 1-2911), remain calm and quiet.

·        Remain concealed until you hear the "All Clear" announced by the paging system.

Table of Contents

Code Blue – Cardio/Pulmonary Arrest

In Case of Cardiac Arrest, or a Medical Emergency, follow this procedure:

·        Contact paging operator at 1-2222.

·        Give location and as much information as possible; i.e., age/sex/circumstances

·        Stand by to assist until Code Team arrives

·        Keep bystanders from interfering with procedures, and clear area for the Code Team when they arrive.

Table of Contents

Code Green - Weather Alert

·        Contact your supervisor for the latest instruction.

·        Locate the nearest National Oceanic and Atmospheric Administration (NOAA) weather radio.

·        Prepare to take cover.

·        If instructed to shelter in place, move patients into designated location, and close doors.

·        Remain calm, and await further instructions

Table of Contents

Code Grey – Bomb Threat

In the event of a CODE GREY the following actions are necessary:

1.      Divide the department or unit between personnel. Assign specific areas to be searched for suspicious devices.

2.      Make a very systematic and complete search. Cover all assigned areas. STOP-LOOK- LISTEN for suspicious items or sounds. Mark areas that have been cleared with tape.

3.      Conduct your search quickly and quietly. Do not cause panic by your search techniques.

4.      If a suspicious device is found, alert your supervisor, DO NOT TOUCH.

5.      Contact Security at 1-4787

6.      If a call is received, click on Questions to ask Caller and complete the form.

Table of Contents

Code Orange - Decontamination

A Code Orange is called

1.      Upon presentation of a patient to the Emergency Department who is believed to have been exposed/contaminated with a hazardous, or potentially hazardous, substance

2.      Upon notification of Emergency Department by a credible source that patient(s) believed to have been exposed to a hazardous, or potentially hazardous, substance are en route to the hospital

3.      Upon request from a Regional hospital or agency for the Community Decon Center to be opened


In all cases where the source or the release is brought to the hospital:

·        Persons contaminated are not to enter any part of the hospital until decontaminated; unless they are in life-threatening medical condition

·        Dial 9-1-1. and give all information available

·        Initiate Lockdown Procedures

·        Shut Down Air Handling Systems

·        No hospital personnel should enter the vehicle.

·        Liaison Officer will make contact with responding Fire Department Scene Commander.

·        All Personnel should shelter in place.*

·        Establish containment areas at all entrances within 300 meters of source.

*Activation of Code Triage or Code Orange should be discouraged until Fire Department contains the source. Any action which would force personnel to move between buildings may endanger their lives.

Table of Contents

Code Pink - Infant/Child Abduction

In Case a Infant/Child abduction or pediatric elopement follow this Procedure:

·        Immediately move to your designated position. Assure all exits are observed; doors, stairwells, elevators etc.

·        Notify Security of any suspicious person or activity (oversized bags, bundles or any item large enough to conceal a child) 1-4787

Table of Contents

Code Red - Fire

Notes and precautions

Small fires can be extinguished without evacuation. However, an immediate readiness to evacuate is essential in the event the fire cannot be controlled. Only trained personnel should use fire extinguishers. Never enter a room that is smoke filled. Never enter a room containing a fire without a back-up person. Never enter a room if the top half of the door is warm to touch.


In case of Fire follow this Procedure:

1.      Remove persons in immediate danger of the fire.

2.      Activate the nearest fire alarm box and call Safety and Security 1-4787. Give location and information.

3.      Confine/contain fire by closing doors.

4.      Evacuate. Move staff and patients horizontally if possible, but only as directed b supervisor or manager.

5.      Remain calm. Never yell “FIRE".

·        Take all fire alarms seriously.

·        Hospital buildings "Defend in Place."

·        Report all fire and smoke incidents.

·        Know the location of your emergency equipment (Exits, Alarm pull stations, Fire Extinguishers, etc.)

·        Do not use elevators during a fire emergency.

·        When fire drills are conducted staff members are required to perform as they would during a real incident.


How Fire Extinguishers Work:

Your fire extinguisher must fit the fire. Fire extinguishers are classified by the type of fire they will put out - "A", "B”, “C” or "ABC". Using the extinguisher that's not rated for the fire you are fighting may make the fire worse! Its particularly dangerous to use a water or a class 'A' extinguisher on a class "B" or "C" fire. Multipurpose extinguishers are rated for more then one kind of fire. An "ABC" extinguisher puts out most types of fires - wood, paper, cloth, flammable liquid and electrical fires. Know what kind of extinguisher you have in your area! Extinguishers have their limits. A portable fire extinguisher can save lives and property by putting out small fires. However, portable extinguishers are not designed to fight large or spreading fires. The operator must know how to use the extinguisher quickly, without taking time to read the directions. Know what to do before a fire happens in your area. Most portable fire extinguishers work according to these directions, but some do not. Read and follow the directions on your extinguisher. Protect yourself at all times! Avoid breathing the heated smoke and fumes. If the fire starts to spread or threatens your escape route, get out immediately.


Table of Contents

Code Triage – Diaster/Diaster Drill

1.      Contact your supervisor for the latest instruction.

2.      Report to your assigned duty position:

·        Labor Pool

·        Incident Command

·        Media Center

·        Family Center

·        Decon Area

3.      Code Triage Standby

Table of Contents

Code White – Pager Outage

In case of a pager outage, the Paging Operator will announce "Code White until further notice" via Overhead Pager. Once announcement is made, please follow these procedures:

1.      All non-emergent contacts should be made by use of cell phone or land-line telephone. If emergency contact with an individual is necessary, call 1-3893:

a.       Give the operator the name of the person to be contacted.

b.      Give the operator the extension you are calling from

c.       Remain at the station you are calling from until contact is made.

2.      The paging operator will announce, via overhead page, for your contact to be made.

3.      When the Code White has ended, the Paging Operator will announce via overhead pager. All paging operations will then return to normal.

Table of Contents

I.E.Q. – Indoor Environmental Quality

In the event of all miscellaneous and/or nuisance:

·        Noxious Odors

·        Dust Problems

·        Noise

·        For Indoor Air/Environmental Quality problems or complaints

Contact SAFETY at ext. 1-4787

Table of Contents

Medical Emergency: Immediate Procedures

·        Remain Calm.

·        Initiate life saving measures, if required.

·        Activate the Emergency Response - Call 1-4787.

·        Do not move injured person unless there is a danger of further harm.

·        Keep injured person warm.

·        Attend to injured or contaminated persons and remove them from exposure.

·        Alert people to evacuate the area.

·        Close doors to affected area.

·        Have person knowledgeable of incident and laboratory to assist emergency personnel.




Biological Safety 1-4787

Chemical Safety 1-4787

Fire Safety 1-4787

Employee Health 1-3418

Radiation Safety 1-9826

Health Systems Safety and Security 1-4787

Table of Contents

Personal Injury

Clothing on Fire

·        Roll person around on floor to smother flame, or drench with water if safety shower is immediately available.

·        Obtain medical attention, if necessary.

·        Report incident to supervisor

Biological Spill on Body

·        Remove contaminated clothing.

·        Vigorously wash exposed area with soap and water for one minute.

·        Obtain medical attention, if necessary.

·        Report incident to supervisor and Safety Office.

Radiation Spill on Body

·        Remove contaminated clothing.

·        Rinse exposed area thoroughly with water.

·        Obtain medical attention, if necessary.

·        Report incident to supervisor and Radiation Safety Officer.

Hazardous Material Splashed in Eye

·        Immediately rinse eyeball and inner surface of eyelid with water continuously for 15 minutes.

·        Forcibly hold eye open to ensure effective wash behind eyelids.

·        Obtain medical attention.

·        Report incident to supervisor.

Chemical Spill on Body

·        Flood exposed area with running water from faucet or safety shower for at least 5 minutes.

·        Remove contaminated clothing.

·        Obtain medical attention, if necessary.

·        Report incident to supervisor

Minor Cuts and Puncture Wounds

·        Vigorously wash injury with soap and water for several minutes.

·        Obtain medical attention.

·        Report incident to supervisor.

Note: Report to Employee Health or Emergency Services for medical attention and treatment.

Additional Site Instructions:

Know the

1.      Location of your nearest Safety Shower

2.      Location of the nearest Eyewash Fountain

Table of Contents

Radiation Spill

Notes and Precautions:

Spreading of radiation beyond the spill area can easily occur by the movement of personnel involved in the spill or cleanup effort. Prevent spread by confining movement of personnel until they have been monitored and found free of contamination. A minor radiation spill is one that the staff is capable of handling safely without the assistance of safety and emergency personnel. All other radiation spills are considered major.


Minor Spill of Radioactive Material - (Less than 1 Millicurie [mCi])

·        Alert people in immediate area of spill

·        Wear protective equipment - including safety goggles disposable gloves, shoe covers, and long-sleeve lab coat.

·        Place absorbent paper towels over liquid spill. Place towels dampened with water over spills of solid materials.

·        Using forceps, place towels in plastic bag. Dispose in radiation waste container.

·        Monitor area, hands, and shoes for contamination with an appropriate survey meter or method.

·        Repeat cleanup until contamination is no longer detected.


Major Spill of Radioactive Material (Millicurie Amounts)

·        Attend to injured or contaminated persons and remove them from exposure.

·        Alert people in the laboratory to evacuate.

·        Have potentially contaminated personnel stay in one area until they have been monitored and shown to be free of contamination.

·        Call Radiation Safety Office at ext. 1-9826

Table of Contents