Date of Graduation

Summer 8-9-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Mary Seed



  • A small community hospital in northern California implemented a practice improvement project in critical care units to optimize best practices surrounding a “code blue” event. In-Hospital Cardiac Arrest (IHCA) is a high-risk process of care that requires tremendous resources to deliver an efficient, safe, and cost-effective service. The code blue recorder sheet summarizes the whole patient care event; this necessitates careful documentation. As a risk anticipator, the unit clinical nurse leader identified suboptimal variation in documentation after a microsystem assessment. This led to a practice change project and targeted educational intervention for code blue recorders. Fifteen staff members were identified from every shift to cover all IHCA events. Baseline data indicated that the completion and accuracy of the code blue documentation were critically low. A literature review revealed best practices with an evidenced-based educational approach including thorough assessment and responsiveness to staff learning needs and preparedness, enhancing knowledge and building confidence to impact patient care outcomes. Results of the educational intervention demonstrated significant improvements in team member confidence in the skills specific to their role and responsibilities. Completion and accuracy data indicated that the rate improved from the baseline of 17% to 67% over the two-month period of training. Clearly, in high acuity and high-risk events such as IHCA, unit leaders need to carefully define the division of labor, role clarity, staff learning needs to implement, and maintain best practices in code blue documentation.

CMPosterFinal - a.pdf (2785 kB)
Poster Project Presentation