The ergonomics of "Code Blue" medical emergencies: a literature review

Justin B. Rousek, M. Susan Hallbeck

Research output: Contribution to journalReview articlepeer-review

7 Scopus citations


"Code Blue" or medical emergency resuscitation events (codes) are inherently chaotic acute crises that are characteristically unpredictable, yet certain to occur. Between 250,000 and 750,000 hospital codes occur annually in the United States; however, successful resuscitation remains elusive in most hospitals with a survival rate of 0-59% with a mean of about 20%. These poor outcomes may be attributed to poor ergonomic (human factors) conditions within the hospital setting and emergency procedures. To determine if ergonomic principles are appropriately being incorporated into several aspects of code events and training, a comprehensive literature review was completed during this study. This review of relevant literature focused on the cognitive and physical ergonomic concerns regarding several factors affecting poor code outcomes. The factors include code team training and proficiency, physical aspects of cardiopulmonary resuscitation (CPR), crash cart factors and the physical and simulated environment during a code. This review determined several aspects of codes that involve poor ergonomics (e.g., training, CPR chest compressions, and crash cart contents) and best practices (e.g., CPR audio prompts, simulation training methods, and code debriefing). Understanding and identifying the ergonomic risks and hazards in code procedures and training may help with future code quality improvement initiatives focusing on patient safety in the healthcare industry.

Original languageEnglish (US)
Pages (from-to)197-212
Number of pages16
JournalIIE Transactions on Healthcare Systems Engineering
Issue number4
StatePublished - 2011


  • Code Blue
  • Healthcare
  • crash cart
  • ergonomics
  • lean engineering
  • simulation

ASJC Scopus subject areas

  • Safety, Risk, Reliability and Quality
  • Safety Research
  • Public Health, Environmental and Occupational Health


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