Improving your Mock Code Blue Program

Mock Code Blue in Action


Working on improving your code blue training program, from planning through to the mock code blue checklist and debriefing, is vital to ensuring competent staff and the safety of your patients in the event of a cardiopulmonary arrest.

There are around 200 000 in-hospital cardiac arrests in the US every year, with a survival rate of between 15% and 25%. While mortality is mostly related to the patient’s underlying condition, survival rates are also influenced by the effectiveness of resuscitation.

Developing the skills of all staff who may be part of responding to a code blue should be a top priority for all health care organizations and this is one area where teaching and learning through simulation is essential.  Cardiopulmonary arrest does not occur frequently, but when it does it is a life-threatening situation and the team needs to function optimally – learning through experience in the real situation is not an option.



Mock Code Blue in Action

The need for regular mock code blue experiences

Simulation training provides learners with the opportunity to apply the theory which they have learnt and gain competence and confidence in skills and procedures without putting patients at risk. Simulation training is ideal to prepare staff for situations which occur infrequently but pose a high risk, and this includes resuscitation.

Research has shown that mock code blue training exercises do significantly improve staff confidence and skills – leading to more rapid responses, greater compliance with prescribed resuscitation standards, fewer errors, and improved communication and teamwork.

Furthermore, with effective observation and recording, mock code blue exercises also provide the organization with data about the level of advanced life support skills of their staff, their strengths and weaknesses, and whether overall performance is improving over time.

Simulation training every three months has been shown to significantly decrease time to start of chest compressions and defibrillation. However, for an overall improvement in the code blue response within an organization the simulation exercises should be conducted regularly because knowledge and skills deteriorate within weeks when they are not used in practice.  

A further significant reason for regular practice is that a code blue evokes an emotional stress response, irrespective of the person’s level of experience. The anxiety response causes the brain to fall back on subconscious frames of reference and this affects a person’s ability to think logically and rationally. Regular mock code blue practice, followed up with debriefing and feedback on performance, contributes towards fast and automatic responses with fewer errors.

Arranging your mock code blue scenario

Staff members will have attended a course in Advanced Cardiac Life Support. They will have been taught the theory and then practiced the skills the teaching laboratory.  As seen in the previous section, however, regular practice is necessary to retain the knowledge and skills, and to gain confidence.

Every health care facility is different and you should plan your mock code blue program according to the facilities and equipment which are available and the needs of your organization and staff.  You also need to obtain buy-in by management and coordinate with senior staff members on the units as the simulation exercises do interfere with the participants’ regular duties.

A cardiopulmonary arrest can occur in any unit and at any time so it is important that exercises should be arranged for staff of all units and shifts, and not only for those who are most likely to encounter a code blue. Staff members should be encouraged to take the mock code blue exercises seriously but also be reassured that the performance assessment is for the learning purposes only and will not affect their job.

Ideally mock codes should offer realistic experiences in actual hospital settings with staff being required to respond “on the fly” without prior warning. This provides the best results in terms of learning and providing information on the strengths and weaknesses of staff members, the organization, and the code blue education program as a whole.

The room where the mock code blue takes place should be equipped with the furniture, phone, and oxygen supply similar to the rooms where an actual code would take place.  A crash cart with the usual medicines, defibrillator, and fluids should be close at hand. While a high fidelity manikin is more realistic and displays a variety of vital signs and other data, you can execute a simple mock code blue effectively even if the manikin only has a pulse.

Once the mock code blue starts participants must perform the actions which they would if it was a real code blue. They will need to follow the advanced cardiac life support algorithms and AHA guidelines, communicate clearly and work effectively as a team. Throughout the procedure teaching staff need to observe and evaluate the participant’s performance.

Assessment with a mock code blue checklist

Assessing the mock code blue training exercise is central to the educational experience as the this evaluation will be used to facilitate learning during debriefing.  It provides feedback to the participants about what they did well and what the gaps are in their knowledge and skills. 

The assessments also serve as a record of on-the-job training for individual participants and for the organization as a whole.  These records can be used for planning, reporting, evaluation of the program as a whole, and research. 

Most often assessments are done using standard written checklists. The downside is that while the educator is busy writing they have less chance to observe what is happening and might miss and not record critical items. There are often low levels of reliability between assessors, with widely differing scores even though the same performance was observed.

Technology has greatly enhanced the realism of simulated learning experiences with high fidelity manikins, and now digital technology has been harnessed to fine-tune and improve mock code blue assessments.

Digital mock code blue checklists, such as the Xapiapp, have been developed to record information about individual participants and all other details of the resuscitation process from beginning to end. This includes evaluation of whether all the actions were performed correctly, time frames, and communication and coordination between the team members.  With more extensive data collection, digital recording can greatly improve the reliability and validity of the assessments.


Experienced educators should guide the debriefing which is the final but most important step of the mock code blue.  The actual experiential learning takes place during debriefing as learners analyses and reflect on their experience. They discover where their behavior should have been different which then leads to improved clinical practice in the future.

There are many different models for debriefing but most agree that educators should create a psychologically safe environment which is supportive, free from blame and in which confidentially is assured. 

Using the assessment data collected during the simulation exercise, educators should guide participants towards self evaluation as far as possible.  The three main questions which should be answered are: What went well? What could be done differently next time? What concerns were there about equipment and the safety of the environment?

The participants can also be asked to complete a mock code blue evaluation form which educators can use to improve future training experiences.

Record keeping and reporting

The educator’s final task after each mock code blue is record keeping. When you have paper records this usually involves extensive filing and/or data capturing.  The time it takes to complete this work, and also all the required reports, can be reduced considerably by using a fully digitized mock code blue checklist.

By using a digital mock code blue checklist the data can easily be transferred and synchronized across various platforms for the following:

  • Updating the training records of individual staff members.
  • Automatic identification of individuals, professional groups, or areas in the hospital where more training is needed.
  • Identifying points where there are frequently errors so that focused teaching sessions can be planned (for example using the defibrillator correctly, or the role of the team leader).
  • Future scheduling of the mock code blue exercises.
  • Compiling reports on the mock code blue program, with detailed graphics and spreadsheets.
  • Conducting research on the mock code blue program, for example how staff knowledge and skill improve over time.

Improving your program with the digital mock code blue checklist

It is clear that the mock code blue program is one of the most important on-the-job training programs in any health care facility. All members of the health care staff need the knowledge and practiced skill to confidently manage cardiopulmonary arrests so that unnecessary fatalities can be prevented.

A digital platform for capturing performance during mock code blue simulations can help you to improve the quality of your program and also save you time. Assessments using  digital mock code blue checklists will be more comprehensive and reliable. This will also support an improved debriefing experience and streamline the program’s overall administration.

You can download our digital mock code blue checklist for free or click on the link to sign up for a Xapiapps trail account.


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