Pennsylvania Patient Safety Advisory Do Community Wristbands Present a Patient Safety Risk? Recently, the Pennsylvania Patient Safety Authority facilities. The 139 survey respondents represented received the following query from a Patient Safety one-third of the combined number of healthcare Officer (PSO) in Pennsylvania. facilities. The survey solicited whether the PSOs’ facilities required patients to remove community Our organization is moving to standardize the wristbands they may have been wearing outside the armband colors per the suggestions from the healthcare facility. One-third of the respondents Pennsylvania Patient Safety Authority. We’ve read about also taking the step of “not allowing said yes, 14% said sometimes, and more than half patients to wear recognition armbands while (53%) either said no or that they did not know.1 in the organization” (e.g., pink breast cancer awareness bands, yellow Lance Armstrong The Authority recognizes the potential for confusion bands). Does the Authority have evidence to between community wristbands and hospital color- suggest that events have been prevented by coded wristbands if the community wristbands are taking this step? Phrased another way, has the inadvertently interpreted as hospital wristbands, Authority received “near misses” indicating that resulting in inadequate or incorrect care being the potential for error exists? The color bands delivered to patients, particularly in emergent situ- we intend to purchase will be much wider ations. Other sources of confusion may include than the recognition bands and will have the situations when patients are transferred among stamped verbiage of the reason for the band clearly listed (e.g., fall prevention, allergy). facilities or when patients are cared for by clini- Please provide some evidence to assist us with cians who work in multiple facilities. Facilities may our risk assessment as we move forward with consider prohibiting community wristbands in the our decision. healthcare setting. If patients do not consent to the removal of these community wristbands, covering From June 2004 to August 2009, there were them may be a viable alternative. no near misses (i.e., Incidents) or Serious Events reported to the Authority involving community The Color of Safety Task Force’s Patient Safety: wristbands (i.e., colored wristbands, not affiliated Color Banding Standardization and Implementation with healthcare color designations, pertaining to Manual standardizes the use of hospital color- charity sponsorship or fashion). However, remov- coded wristbands and addresses consistency in ing community wristbands from patients may avert wristband meanings. This manual also addresses potential confusion with hospital color-coded hospital colored-coded wristband application wristbands, particularly during an emergency. The and the potential problems that may arise.2 The Authority has received reports involving patients manual, other patient safety tools, and articles being admitted with colored wristbands applied by published in the Pennsylvania Patient Safety Advi- other healthcare facilities that may conflict with the sory constitute a color-coded wristband toolkit admitting facility’s policy. The Authority also has available on the Authority’s Web site at http:// received reports from hospitals that standardized patientsafetyauthority.org/EducationalTools/Patient- on the Color of Safety Task Force model, in which SafetyTools/wristbands/Pages/home.aspx. clinicians applied outdated or leftover wristbands that were not collected and disposed of during Notes implementation of the new policy. Other reports 1. Use of color-coded patient wristbands creates unneces- submitted to the Authority describe events in which sary risk. PA PSRS Patient Saf Advis [online] 2005 Dec clinicians nearly failed to identify a hospital wrist- 2 [cited 2009 Aug 20]. Available from Internet: http:// band color’s designation, which could have had patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/ serious consequences. The reports indicated that 2005/dec14_2(suppl2)/Pages/dec14;2(suppl2).aspx. confusion occurred when a clinician incorrectly 2. The Color of Safety Task Force. Patient safety: color placed a wristband on a patient or could not iden- banding standardization and implementation manual tify the meaning of a color-coded wristband. [online]. [cited 2009 Aug 20]. Available from Internet: http://patientsafetyauthority.org/EducationalTools/ In 2005, the Authority surveyed the PSOs of all PatientSafetyTools/wristbands/Pages/wristband_ Pennsylvania hospitals and ambulatory surgical manual.aspx. Page 140 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 4—December 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania 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 Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication 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 nonpunitive approach and systems-based solutions.