Q2 2023 LLUH-Wide Code Gray

All hospital units and departments

Unit/Department Staff

Follow the instructions of your unit’s Drill Facilitator (Charge RN, Safety Coordinator, Clinical Educator) to participate in the Code Gray Drill.

1. Complete pre-drill education with Drill Facilitator on Code Gray Response Protocol and safety briefing (no physical contact during drill, do not call Security – verbalize actions only). 
2. Respond to the “Code Gray – Combative Person” incident using the S.A.N.D. acronym (Safety First, Assemble Team, Notify, and De-escalate). 
3. Participate in the drill debriefing, identify where to submit a workplace violence report, and review additional workplace violence prevention resources. 

Please note there should be no disruption of patient care or business operations during this drill.

Drill Facilitators
(Charge RNs, Safety Coordinators, Leadership)

Using the Code Gray – Combative Person/WPV Response Facilitator Guidebook:

1. Gather available employees and conduct a verbal review of the Code Gray Response Protocol. 
2. Advise staff there is to be NO physical contact during the drill and Security should NOT be called or alerted via panic buttons (verbalize notifying Security only).
3. Notify non-participating staff, patients, visitors, and family using the “drill in progress” cards from the Facilitator Guidebook.
4. Conduct Code Gray Scenario and observe response.
5. Conduct a debriefing and review of WPV resources with staff.
6. Document Code Gray Drill participation using the online Code Gray Drill Evaluation. 

Following the completion of Code Gray Drill on May 25th, please join us at 3:00 p.m. for a Hotwash/Debriefing via Teams:

Join on your computer, mobile app or room device

Click here to join the meeting  

Out-patient Units, Business and Academic Departments

Your participation in the Code Gray – Combative Person drill is always welcome, but not required. 

If you would like to participate, please follow the instructions for hospital units and departments.