During remodeling and renovation of two patient care areas at a hospital, a new nurse call system was installed. A Code Blue alarm specific to each room was a component of the new nurse call system. The other patient care areas in the hospital were to receive the new nurse call system later in the year. Following installation of the new system, the nurses were instructed to begin using the Code Blue button in patient rooms, and they were assured that the alarm and room number would automatically appear on the hospital operator’s console. The new system made it unnecessary to call the operator to request a “Code Blue” and for the operator to announce the room number because it was done automatically. Unfortunately, this was a case in which patient safety was overlooked in the excitement of receiving new technology. It was soon discovered that the room number that appeared on the console did not correspond to the room number in which the button was being pushed. The discrepancy was noted with the first Code Blue in one of the renovated areas when the room number that appeared on the console was not a recognized room number in the hospital. Use of the Code Blue button was suspended immediately.

• Discuss your thoughts on how the hospital could have avoided this patient safety mishap.
• What steps should the hospital now take to fully implement the new system in a safe manner (think staff education, safety guidelines and regulations)?