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critical part of safe and comprehensive patient care. These in-hospital cardiac arrest emergencies are commonly called “code blue” emergencies and require treatment by a “code team” comprised of trained healthcare providers. The code team is frequently follows a set of guidelines released by the American Heart Association (AHA), collectively known as the Advanced Cardiac Life Support (ACLS) algorithms. 6 These algorithms are regularly updated to reflect best-practices, particularly for factors known to improve patient outcomes, such as the timeliness and quality of chest compressions, electric shocks, and medications. Unfortunately, the national survival-to-discharge rate for in-hospital cardiac arrest events remains relatively unchanged despite advances in medical care. 7 Therefore, efforts to improve patient outcomes have begun focusing more on improved communication and documentation. 8,9 The most critical function of real-time code blue documentation is to track the information needed to determine which medications and procedures should be used. Access to real-time information allows physicians to make informed decisions that can influence patient outcomes. It also serves as an ongoing record for follow-up care and quality improvement, as well as providing a retrospective record of care in the case of an adverse outcome. The paper forms are based on the Utstein-style template, which outlines the data elements to capture during and after a cardiac arrest event occurs. 10 Despite the availability of the Utstein-style template and previous literature discussing its use in reporting in-hospital cardiac arrest, there has been little 8 reported work into how the paper record accommodates the information needs of those who use it to record data. Instead, the literature focuses on the role of documentation in supporting practices known to affect patient outcomes. 11–15 The literature also confirms that in-hospital emergency records are often inaccurate and incomplete. 16,17 The literature on emergency documentation is limited to outcomes measures, discussion of form content, and the potential of technology-based solutions. Prior work in the literature primarily examines the potential of technology-based replacements for documentation, including desktop-based computers and alternative technologies such as electronic clipboards. 18–20 The literature also includes research into automated voice capture as documentation method. However, the literature also cautions that automated documentation systems may not be well-suited for the emergency setting. 21 Specifically, the literature cites difficulties with using automated voice-recognition systems in an emergency setting, since ambient noise can interfere with the ability of an automated system to capture data correctly. 22 In contrast, this research seeks to understand the root causes responsible for gaps in real-time data collection. Materials and methods Research setting This research was conducted at the University of Washington Medical Center, a regional teaching hospital for the Pacific Northwest region with 450 patient beds. During the 2008 calendar year, the facility admitted more than 19,000 patients, who were housed in various in-patient hospital units throughout the facility. The facility included 21 separate patient care areas, each with their own assigned care staff. Each of these units housed a code cart containing medications and equipment, including a set of paper-based documentation forms used to record events during a code blue 9 emergency. The documentation form was kept within the locked code cart, and so it was only accessible when the cart was unlocked during an emergency. When an incident did not require the use of a code cart, no code blue documentation was generated. Subject populations To better understand the role of code blue documentation in the clinical setting, this research began by identifying the groups of stakeholders who use information from the documentation form. These groups were identified as the physicians who use documentation to direct real-time care, the nurses who record information on the documentation forms, the patient safety staff who review each form to assess system-wide quality of care, and the risk management staff who relied on documentation forms to provide legal accountability in the event of an adverse outcome. All of these groups had expressed dissatisfaction with the quality and completeness of existing code blue documentation. Physician information needs were driven by best practice guidelines such as the advanced cardiac life support algorithms. These algorithms provided the basis for the required clinical content of the forms, such as the time that specific medications were administered. This prompted a records review to determine whether or not essential pieces of information were incomplete and to what extent. Because the recording nurses were directly responsible for recording the information in a timely manner, they comprised the next group of stakeholders. This research focused specifically on the “STAT” nurses, a sub-group of highly-trained nurses who regularly responded to cardiac arrest emergencies and retained a large amount of institutional wisdom. Patient safety personnel comprised another important stakeholder group. They collected the 

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