Patient Safety Advisory Produced by ECRI & ISMP under contract to the Patient Safety Authority Vol. 2, Sup. 2—Dec. 14, 2005 SUPPLEMENTARY ADVISORY Use of Color-Coded Patient Wristbands Creates Unnecessary Risk A hospital in Pennsylvania submitted a report to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing an event in which There is wide variation among facilities on the types of clinical information they communicate via color- coded wristbands. Among those that use this clinicians nearly failed to rescue a patient who had method of communication, there is little consistency a cardiopulmonary arrest because the patient had in the colors used to communicate specific clinical been incorrectly designated as “DNR” (do not re- information (see Table 1). suscitate). The source of the confusion was that a nurse had incorrectly placed a yellow wristband on The potential for confusion is obvious and sig- the patient. In this hospital, the color yellow signi- nificant. About one in seven survey respondents fied that the patient should not be resuscitated. In a use wristbands to communicate a patient’s DNR nearby hospital, in which this nurse also worked, status. Of those, over half use the color blue to indi- yellow signified “restricted extremity,” meaning that cate patients designated as DNR. In other facilities this arm is not to be used for drawing blood or ob- the same message is communicated using purple, taining IV access. yellow, pink, red, and other colors. Fortunately, in this case, another clinician identified While DNR status may be most commonly associ- the mistake, and the patient was resuscitated. How- ated with the color blue, other facilities use this ever, this “near miss” highlights a potential source same color to signify that a patient: of error and an opportunity to improve patient safety by re-evaluating the use of color-coded wristbands. • Is prone to fall. • Has a pacemaker. To assess the potential scope of the problem, PA- • Is an elopement risk (i.e., may wander off). PSRS surveyed the Patient Safety Officers of all • Has a latex or tape allergy. Pennsylvania hospitals and ambulatory surgical • Is on anticoagulants (blood thinners). facilities (ASFs). The 139 survey respondents rep- • Has diabetes. resented one-third of these healthcare facilities. • Has a name similar to another patient’s. • Should not have blood drawn from this arm. Color-coded wristbands are widely used in • Is an outpatient. Pennsylvania healthcare facilities. Nearly four out of five (78%) survey respondents’ facilities use Highlights patient wristbands to communicate clinical informa- 1. In a recent survey, about four out of five PA facilities re- tion other than the patient’s identity. Of those that sponding use color-coded patient wristbands to communi- do, nearly all (98%) report that color is significant cate important medical information. (i.e., used to communicate the meaning) on some or all wristbands. While color-coded wristband use 2. There are no standard meanings among healthcare facilities for different colors. This problem can be resolved by coordi- appears more prevalent among hospitals, with nation among PA healthcare facilities. nearly 87% reporting that they use them, wristband color-coding is also common among ASFs (67%). 3. Limiting the number and colors of wristbands may help to avoid confusion for the many healthcare providers working Some facilities report using as many as five color- in multiple facilities. coded wristbands, in addition to the patient identifi- cation (ID) band. 4. Printed instructions on wristbands can help to reinforce the message conveyed by a particular color. Vol. 2, Sup. 2—Dec. 14, 2005 ©2005 Patient Safety Authority Page 1 PA-PSRS Patient Safety Advisory Another example of the potential for error found in strong. Only one-third of the respondents an- the survey was that one facility uses a pink wrist- swered affirmatively, and 14% said sometimes. band to communicate patients’ blood types, while Over half (53%) said no or said that they did not another facility uses the same color to identify pa- know. tients who should not receive blood products. Other Common Wristband Errors. The errors Table 1 shows the wide variety of medical that commonly occur with patient ID bands can “messages” and colors used to communicate also occur with color-coded wristbands used to them. Table 2 describes the more common wrist- convey medical information. band uses. Wristbands may be omitted when they should be Compounding the potential for confusion from the put on, or they may be removed or covered up by lack of standardization across facilities is that clinicians or patients. PA-PSRS has received a many wristbands do not contain text that would number of reports in which patient allergy bands provide an additional cue to their meaning. Of the were not applied. In another report, a patient was 108 respondents that use these types of wrist- mistakenly resuscitated because a DNR wristband bands, only 48% use text on all such wristbands in had not been applied as ordered by the physician. use in their facility. Clinicians may not notice a wristband and may therefore provide treatment inconsistent with the We asked all respondents whether their facilities patient’s condition or preferences. For example, require patients to remove colored wristbands they many reports to PA-PSRS describe patients hav- may have been wearing outside the healthcare ing blood drawn from a restricted extremity or re- facility, such as the yellow “Live Strong” wrist- ceiving an intervention to which they have a docu- bands associated with the cyclist Lance Arm- Table 1. Variety of Medical “Messages” and Colors Used on Patient Wristbands in Pennsylvania Facilities Colors Purple Blue Teal Green Red Pink Orange Yellow White Message DNR Limited DNR Fall Risk Restricted Extremity Allergy (other than latex) Allergy to Latex Tape Allergy Procedure Site Blood Type/Blood Bank ID No Blood Products Outpatient or ER Patient Pediatrics/Mother-Child Match Parent/guardian Similar Name Observation Isolation Elopement Pacemaker Anticoagulants Nothing by Mouth (NPO) Dietary Restrictions Diabetics Page 2 ©2005 Patient Safety Authority Vol. 2, Sup. 2—Dec. 14, 2005 PA-PSRS Patient Safety Advisory mented allergy, despite having color-coded wrist- • Use only primary and secondary colors. bands applied. Avoiding use of shades of the same color to convey different messages can help Wristbands are sometimes removed during medi- reduce potential confusion. cal procedures, such as surgery or when starting an IV. Facilities have submitted many reports to • Use brief, pre-printed descriptive text on PA-PSRS about ID bands or other wristbands be- wristbands to provide clarification to clini- ing temporarily removed and not reapplied. Forget- cians. This can minimize misperception of ting to reapply a wristband can be avoided by insti- colors in dimly lit patient rooms and allevi- tuting a practice of removing a wristband from one ate confusion for color-blind caregivers. extremity only after a duplicate one has been Text may also help reinforce the color- placed on another extremity. coding system for new clinicians. Wristbands are sometimes applied in error. For example, PA-PSRS received a report in which a • Emboss or pre-print text rather than using color-coded wristband was applied to indicate that handwriting. Handwriting on wristbands a patient had been cleared for a surgical proce- should only be done in an emergency. dure and that all necessary documentation was in Writing on wristbands, as is often done place. During a pre-surgery “time out,” in which with allergy bracelets, is best avoided. critical information is reconfirmed before proceed- [Remember: an allergy wristband is not ing, the clinical team discovered the patient had intended to be a sole source of informa- not consented for anesthesia. What kept this “near tion, but is a warning to the clinician to miss” from becoming an adverse event was that confirm the allergy status with the patient the surgical team did not rely on a single piece of or to review the allergy history on the pa- evidence (the wristband) for confirmation. When tient’s chart.] faced with contradictory information (lack of docu- mentation that consent was obtained), they de- • If your facility uses wristbands for pediatric layed the procedure to resolve the discrepancy. patients that relate to the Broselow color- coding system for pediatric resuscitation What Can Healthcare Facilities Do? The follow- carts, consider the potential for confusion ing guidance will help facilities avoid unanticipated between the Broselow bands (which are adverse events, if they choose to use color-coded most likely to be used in the Emergency wristbands: Department, Pediatrics, and Neonatal In- tensive Care) and other colored wrist- • Limit the number of different colors in use bands your facility uses. on patient wristbands. • Explain to patients and/or their families the • Standardize the meanings of specific colors purpose of all wristbands as they are put among healthcare facilities. on. This provides an opportunity for them Table 2. Medical Information Commonly Communicated with Wristbands Dominant Color Number (%) of Facilities Using Number (%) of (% of Facilities Text/Symbols on Colored Clinical Topic Facilities Using* Using)† Wristbands† Allergies 82 (76%) Red (78%) 48 (56%) Fall Risk 45 (42%) Green (31%) 8 (23%) Restricted Extremity 34 (32%) Purple (27%) 8 (24%) DNR Status 21 (19%) Blue (52%) 4 (19%) Blood Type/Blood Bank ID 13 (12%) Red (92%) 9 (69%) *Percentages are based the 108 facilities indicating that they do use color-coded wristbands. †Percentages are based on the number of facilities indicating that they use a color-coded wristband for this clinical topic. Vol. 2, Sup. 2—Dec. 14, 2005 ©2005 Patient Safety Authority Page 3 PA-PSRS Patient Safety Advisory to identify errors. This also reinforces a fa- • Consider making wristband verification part cility’s commitment to promoting a culture of the nursing assessment during shift of safety by encouraging patients and their changes. families to participate in efforts to prevent • Make it clear in policies and procedures errors. who has responsibility and authority to • Consider removing colored wristbands that place wristbands on patients and that all patients may be wearing when they present staff have a role in making sure any errors to the facility. Explain the hazards to pa- or omissions are quickly corrected. tients who refuse, and cover the wristband with a bandage or medical tape. While human error can never be eliminated, these steps can help to reduce the potential for the sys- • Consider instructing staff to periodically tem itself to contribute to errors. Short of eliminating reconfirm with the patient or family the meaning of wristbands that have been ap- the use of color-coded wristbands or standardizing plied and to correct errors immediately. For the meaning of specific colors, facilities should im- example, reconfirmation might be done be- plement procedures to ensure that the messages fore invasive procedures, at transfer, and conveyed through color-coded wristbands are cor- during changes in level of care. rectly interpreted. An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organi- zations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medi- cation error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 4 ©2005 Patient Safety Authority Vol. 2, Sup. 2—Dec. 14, 2005