The Emergency Nurses Association (ENA) supports using plain language alerts, citing the wide variation in codes that were in use throughout the country before the gradual move to more direct communication.

In its position paper on plain language, ENA provided examples of how the risk from confusing and ambiguous codes is more than theoretical. “The difference between coded alerts and plain language alerts can be seen in the contrast between active shooter situations at West Anaheim Medical Center (WAMC) in 1999 and at Brigham and Women’s Hospital in 2015,” the ENA paper authors wrote. “At WAMC, there was no specific color code for an active shooter, and the coded alert system, by its very nature, prohibited adaptation of established codes to novel situations.

As a result, ‘Code Gray’ was announced, which indicated the presence of a combative person. However, the Code Gray protocol at WAMC directed male staff members to respond and help control the situation, which drew them toward the shooter and resulted in two of them being killed.” By the time it had an active shooter incident in 2015, Brigham and Women’s hospital had replaced coded alerts with plain language alerts. The hospital’s announcement said, “A life-threatening situation now exists at Watkins Clinic B, Shapiro 2. All persons should immediately move away from that location if it is safe to do so. If it is not safe to move away, shelter in place immediately.”

The ENA paper cited research from Pennsylvania healthcare facilities between 2004 and 2013 showing that they used 80 different emergency codes to designate 37 separate functional categories. That meant there were 154 possible combinations to interpret correctly. This was the state of codes used by Pennsylvania facilities:

  • 15 different codes for “combative person”;
  • 15 for “internal/external emergency”;
  • 15 for adult medical emergencies;
  • Code Yellow carried 10 meanings;
  • Code Orange carried nine meanings;
  • Codes Purple, White, and Silver each carried seven meanings.

The Pennsylvania hospitals also used 16 different letter codes, such as Code A, and four coded names, such as Dr. Quick. There were 12 number codes and 22 word codes, such as Code Wintergreen. In other research, California used 47 different codes for infant abduction and 61 different codes for a combative person. The ENA research summary and position paper is available online at: