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key takeaways

  • Code Blue performance is more than adherence to resuscitation algorithms alone. Human factors, like leadership and teamwork, are equally important.
  • Strategies for strong Code Blue leadership include: clear communication, building psychological safety, and team debriefing after the code.

Code Blue performance is far more than the correct execution of basic life support algorithms alone. Human factors — such as teamwork, leadership, and the collective ability to perform under pressurealso play a key role in performance.1,2 In fact, studies have shown that teamwork and leadership often have a direct effect on adherence to algorithms during a code.1

Strong leadership is an especially important part of the equation, but that doesn’t mean it’s easy. To start, many Code Blue teams are formed ad hoc, so leaders have the difficult task of organizing and directing a group of clinicians who may be working together for the first time. On top of that, studies show that the dynamics of hierarchies within code teams — typically with one clinician at the helm, directing the group and making key decisions — can sometimes have the unintended effect of inhibiting others from speaking up or sharing concerns.2,3

So what can leaders do to overcome these challenges, build psychological safety, and elevate the entire team’s performance? Keep reading for 3 key strategies to use.

Strategy 1: Get everyone on the same page

It’s no secret that there are a lot of moving parts during a code. One of the most important jobs of the leader is to communicate clearly and ensure everyone is moving in the same direction and working toward the same objectives. Easier said than done, but here are some key strategies that can help:

  • Think out loud. Studies show that providers who share key observations out loud and update the team periodically as new information becomes available perform better.2 Why? Doing so is one of the best ways to establish and maintain a shared mental model, which is basically the team’s shared understanding of the patient’s situation and where the team is going. Articulating this mental model at the beginning of the code and at certain checkpoints throughout is essential.4
  • Clearly communicate transfers of leadership during the code. Sometimes the situation may call for a temporary transfer in leadership: for example, if the team lead needs to leave the room or perform a task that requires total focus.4 When this happens, clearly communicating those transitions to the whole team will avoid confusion or a vacuum in leadership, which is the last thing you want during a high-stakes emergency. Using closed-loop communication can also help ensure smooth transfer of leadership when needed.

Strategy 2: Build psychological safety

Team psychological safety is defined as “the shared belief that the team is safe for interpersonal risk taking.”5 Why is this important? In a healthcare setting, this looks like clinicians feeling comfortable enough to ask questions, voice concerns, and give feedback — behaviors that are critical in responding optimally in intense emergency situations like Code Blues.6

And while that feeling of safety is partially determined by individual personality, it is also heavily influenced by team culture.6 The team leader in particular plays a critical role in fostering a psychologically safe environment. So how to do it?

  • Ask for other opinions. After establishing the shared mental model in the beginning of the code, for example, actively solicit feedback from the team: “What am I missing? What else should we be thinking about?”4 Put simply: Ask for feedback instead of waiting for others to speak up. An added benefit of this approach? Studies of team hierarchical dynamics have shown that it’s key for all team members to contribute early during a crisis — versus only high-ranking members providing information at the outset.2
  • Respond well when people do offer input.4 This doesn’t mean you always have to implement the other person’s suggestion, but you can still provide a quick explanation as to why and thank them for their feedback.4 Time constraints may make this difficult during the code, but a simplified version will suffice. Then circle back to it afterward, during the debrief.

Strategy 3: Strengthen team unity with debriefing

Debriefing is important from a practical perspective: to learn from the event and do better next time. But it also has implications for team cohesion and trust, which can only be nurtured over time through small touchpoints like this.

From a leadership standpoint, the leader’s role doesn’t stop at the end of the code. An effective leader will set the tone in the immediate aftermath of the event too. This is important regardless of the code’s outcome, but especially if the patient didn’t survive.4 Emotions may be running high, and how the leader handles the post-code discussions is crucial in solidifying a positive team culture. Here are some tips:

  • Highlight the expertise and contributions of team members. Don’t limit this to hands-on, clinical contributions (although those are clearly important). Think about psychological safety as well. For example, recognize a team member who took the initiative to speak up in a difficult moment.
  • Talk about what went well during the code in addition to what can be improved. Both are equally important, so resist the temptation to focus solely on what went wrong.
  • If there were missteps or errors, avoid blame. Instead, look to understand why something happened.4 Always emphasize that Code Blues are incredibly complex events, and outcomes — good or bad — are never the result of one person’s actions alone.4


Read on

Next up, learn key strategies ad hoc Code Blue teams can use to improve performance.


  1. Shah P, Havalad V. (2021). A novel code team leader card to improve leader identification. Journal of Patient-Centered Research and Reviews, 8(4): 354-9. doi: 17294/2330-0698.1847
  2. Hunziker S, Johansson AC, Tschan F, et al (2011). Teamwork and leadership in cardiopulmonary resuscitation. Journal of the American College of Cardiology. 57(24).
  3. Akamine Y, Imafuku R, Saiki T, et al. (2021) Physicians’ perceptions of followership in resuscitation in Japan and the USA: a qualitative study. BMJ Open. doi:10.1136/bmjopen-2020-047860
  4. Alvarez A, Bucks C, Cline PB. High Performance Resuscitation Teams: Time Zero Series Online CME Course. Mayo Clinic School of Continuous Professional Development.
  5. Rosenman ED, Fernandez R, Wong AH, et al. (2017). Changing systems through effective teams: a role for simulation. Academic Emergency Medicine.
  6. O’Donovan R, De Brun A, McAuliffe E. (2021). Healthcare professionals experience of psychological safety, voice, and silence. Front Psychol.
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