It is common for hospital staff and visitors to hear coded alerts on the public address system, with Code Blue calls mixing with Code Reds, Pinks, and maybe Oranges.

What is a Code Orange? A staff member may worry this is something important that requires action, but he or she may not know what to do. A patient or visitor may just worry something bad is happening in the hospital and feel left in the dark. What if an employee works at more than one hospital, and a Code Orange in one means a hazardous material incident but in the other it means an active shooter?

More hospitals and health systems are adopting plain language for their emergency announcements, forgoing some traditional code words for situations such as fires and infant abductions. The goal is to reduce the potential for confusion caused by facilities using different codes, and the desire to more effectively communicate with patients and visitors. Twenty-five state hospital associations recommend plain language alerts, and The Joint Commission (TJC) has recommended plain language since 2012. Federal agencies such as Health and Human Services, Homeland Security, and FEMA recommend using plain language for emergency alerts, citing the need for clarity.

For instance, FEMA says first responders and incident managers should use common terminology to promote public safety, especially the safety of those directly affected by the incident. TJC suggests healthcare organizations forgo the traditional Code Red for fire in favor of something like “Facility Alert – Fire Alarm,” followed by more specific information.

Health System Switches to Plain Talk

Piedmont Healthcare recently adopted plain language alerts at its 11 hospitals in Georgia. Part of the impetus for the change was the growth of the healthcare system, which has more than doubled in size in four years.

As each facility joined the Piedmont system, it brought its own codes for facility announcements, says Eric Bour, MD, CEO at Piedmont Newton Hospital in Covington, GA. There was overlap with some of the most commonly used codes, but many facilities used codes that were unfamiliar to health system employees and professionals traveling from one hospital to another.

“Within one facility, it wasn’t a big deal because people were trained to know their hospital’s particular codes,” Bour says. “But ... there is a potential that someone in one facility would not respond correctly to an event because they would not know what that particular color meant in that facility.”

The potential for harm became especially evident with Code Pink. Bour notes that Code Pink is a legacy color code that usually means infant abduction, but it might also mean an infant cardiorespiratory arrest.

“In one event, you want the place locked down and everyone ... doing everything you can to find that infant. If it’s an infant cardiac arrest, you want the code team, and failure to respond appropriately in either case could be disastrous,” Bour says. “Those kinds of disparities in what we think of as a commonly used code were apparent even in two of our hospitals that are practically right next to each other. We have numerous staff that go back and forth to both places.”

Better to Inform

Coded language was used largely because healthcare organizations sought quick, concise ways to alert staff to certain situations, and also to keep certain information from patients and visitors, Bour notes. For example, there was a fear that simply alerting everyone to a fire in the building with plain language might set off a panic. Many considered a code that alerted only a select audience as the better solution.

“But when you really look at it, the data and studies show that people aren’t more afraid when they know what’s happening. They’re actually more afraid when they don’t know what’s happening,” Bour says. “It’s scarier when you hear something is going on but you don’t know what. Your mind fills in the gap with the worst possibility.”1

Piedmont adopted plain language across all its facilities in September 2019, starting with the assembly of a group of staff and leaders who could guide the process. That group included nursing, public safety, emergency management, and communications, including the operators who make public announcements.

The group conducted some research into the hazards of codes and the benefits of plain language, assessing the available data and the position statements of many state hospital organizations and other healthcare groups. (See the story later in this issue for details on research indicating the wide variety of codes in use.)

Piedmont’s group then started presenting that information to departments and units throughout the health system to solicit buy-in. Feedback from that process led to some retooling of their original plan to eliminate all codes.

“We decided to let Code Blue stay the same,” Bour reports. “It’s a very quick way to get the attention of those key people who are needed to respond ... we provided an enunciation tool to all our communications people so that they know exactly what to say in each situation. We educated our staff through our intranet, posters, table tents, and all kinds of things to let people know we were converting.”

No Need to Phase In

There had been some in the health system who insisted that such a change should be made over a six- to nine-month period to allow people to start thinking in different terms and not expect the usual coded messages. Bour pushed back on that, saying there would be no learning curve for the plain language alerts.

“If you state things directly, people will understand what’s going on and determine their most appropriate response,” Bour offers. “It’s the coded language that you have to train people to understand.”

The change took effect in September. Since then, Bour says it has been successful. “There are some soft ways to measure success with something like this, such as how much push back you’re getting in the first 30 days. The answer is we got zero,” he says. “The other measure of success is whether people are responding properly to overhead communication. There have been no safety events because of an improper response.”

Missouri hospitals began seriously considering plain language communication in 2012, notes Jackie Gatz, MPA, CHEP, vice president for safety and preparedness with the Missouri Hospital Association (MHA). An MHA committee that focuses on healthcare continuity of operations during a disaster assessed the use of codes.

As could be found elsewhere, the use of codes was wildly inconsistent across Missouri, Gatz recalls. Nine different codes were used to announce a mass casualty event, meaning someone from a different facility might not recognize a code that should trigger immediate action, she explains.

“Those staff who are moving between different facilities could really be confused by that, and that matters when you’re going to be receiving multiple casualties in 10 minutes,” Gatz says.

The MHA determined that plain language also was becoming the preferred communication method in the field of emergency preparedness. Many public safety and law enforcement organizations now discourage or forbid the use of “10” codes in favor of direct communication. The National Incident Management System has established plain language requirements for communication and information management.2

The MHA urged hospitals to adopt plain language and provided a guide for consistent announcements.3 A hazardous materials incident would be announced as “Facility Alert + Hazardous Spill + Descriptor (location).”

Several varieties of security incidents would be announced as “Security Alert + Descriptor (threat/location).” The descriptor could be a bomb threat, a violent person, an active shooter, or whatever information was necessary for people to respond appropriately.

The MHA guide is voluntary, although the association strongly encourages hospitals to adopt plain language. For those hospitals that are reluctant to use plain language, the guide provides a standardized code for some scenarios so that at least the codes will be more uniform throughout the state. For example, hospitals that do not want to fully commit to plain language for a bomb threat are encouraged to use Code Black.

Keeping Red and Blue

The MHA decided to retain the use of the two most popular codes (Code Red and Code Blue) because they are so well known in the healthcare community and generally to most other people, Gatz says. Some hospitals use Code Blue with a descriptor of the medical emergency to use plain language while still satisfying those listening for the traditional code, she explains.

Gatz notes MHA has pushed harder for the use of plain language in recent years due to the increased concern over violent incidents in healthcare settings. When the plain language initiative began, there were many hospital leaders who believed that security alerts for violent incidents still needed to be cryptic enough not to alarm people, Gatz says. That attitude has changed more recently, and there is widespread support for open communication.

“With some of the violent incidents we’re seeing in our communities and in our healthcare facilities, you almost have a fundamental right to make people aware of a threat that is near them. Denying them that knowledge through coded announcements is not acceptable,” Gatz suggests. “There has been a lot of discussion among safety leaders that you are much better off if you communicate clearly and allow people to move safely away from the threat in the environment.”

Effective plain language communication must not only convey what is happening but also what action is appropriate, Gatz says. That action may be spelled out specifically in the announcement (e.g., “evacuate the third floor”), or it may be surmised by the listener, such as when code team members know they must respond to the stated location.

Expect Little Resistance

About 90% of Missouri hospitals have adopted plain language. Gatz notes some hospitals are trying to decrease the number of overhead announcements. Thus, they are no longer broadcasting certain codes, using more directed methods of communication instead.

Switching to plain language requires a champion who can explain the reasoning to different constituents and overcome barriers, Bour says. However, this improvement project should not meet a great deal of resistance.

Most hesitation is based on tradition, with long-time staff wondering if it is a good idea to let everyone know what is going on in the hospital without any filter, he says.

That skepticism can be overcome by showing the extensive research on how plain language improves safety, Bour says. “If we want to provide the safest environment for our staff, our patients, everyone else in the facility for any reason, then we need to be able to communicate clearly and concisely what is happening,” he says. “We are in an environment, unfortunately, that is very vulnerable to the actions of bad people and bad events. We need to be able to communicate in a way that makes sense to everyone.”


  1. Mawson AR. Understanding mass panic and other collective responses to threat and disaster. Psychiatry 2005;68:95-113.
  2. U.S. Department of Homeland Security. Plain language frequently asked questions (FAQs), June 2010. Available at: Accessed Dec. 2, 2019.
  3. Missouri Hospital Association. Standardized, plain language emergency codes. Implementation guide, 2013. Available at: Accessed Dec. 2, 2019.


  • Eric Bour, MD, CEO, Piedmont Newton Hospital, Piedmont Healthcare, Covington, GA. Phone: (770) 786-7053.
  • Jackie Gatz, MPA, CHEP, Vice President, Safety and Preparedness, Missouri Hospital Association, Jefferson City, MO. Email: