Color-coded wristbands can be patient safety risk

A good idea for improving patient safety could backfire if you are not careful. Many risk managers have endorsed the use of color-coded wristbands on patients to identify allergies, susceptibility to falls, and other risks, but some providers are realizing that there is no standardization of the colors used.

That means the same yellow wristband that means "penicillin allergy" in one facility could mean "do not resuscitate" (DNR) in another. With health care workers migrating from one facility to another as they change jobs or work at several sites, the situation is ripe for a tragic misunderstanding.

When a patient nearly died in a Pennsylvania hospital due to confusion about the meaning of a colored wristband that had been put on the patient's arm, hospital officials in northeastern and central Pennsylvania realized the hazard and decided to work together to develop standards for the use of color-coded patient wristbands in their facilities. The Pennsylvania Patient Safety Authority in Harrisburg reports that the incident involved a patient who was almost not resuscitated during cardiopulmonary arrest because she was incorrectly designated "DNR" with a colored wristband by a nurse who worked in multiple facilities and was confused about the meanings of different colors. Nearly four out of five Pennsylvania facilities use color-coded patient wristbands, the authority reports.

Although the mistake was caught in time, the incident raised the possibility of real patient harm, even death, if a wrong wristband is used. Eleven facilities formed the Color of Safety Task Force to develop detailed protocols, including a policy manual and training resources, to reduce the risk of medical error when using color-coded wristbands. (The task force has made the manual and related materials available to other facilities through the Patient Safety Authority's web site. See sources/resource list for more information.)

In addition to standardizing colors, risk managers must recognize the risk posed by wristbands patients may wear to the hospital, says Mike Doering, interim executive director of the Pennsylvania Patient Safety Authority. Colored wristbands have become popular recently as a way to show support for a particular charity or social cause, and Doering says they also may confuse staff. Even though they do not look exactly like a hospital-issued wristband, the color alone may be enough to cause confusion when seen from afar or glanced during an emergency.

"Risk managers should make sure there is a policy that requires those wristbands to be removed when the patient enters the facility," Doering says. "We have to remember that even if you don't record a real tragedy from that kind of mix-up, there might be a lot of near misses that don't get reported. With the incident that sparked our investigation of this issue, it was a near miss that thankfully was brought to our attention."

Constant risk from color confusion

The goal of the Color of Safety Task Force was to standardize policies and procedures and to implement strategies that reduce the possibility of miscommunication, says Bonnie Haluska, associate vice president of the Allied Services Rehabilitation Hospital in Scranton and chair of the task force. (See article, below, for tips from the task force.)

"Health care workers move from one facility to another, and our patients are transferred all the time," Haluska says. "So all the time, every day, there is the risk that a wristband color can be confused, with dire consequences."

Tips for reducing risks with color-coded wristbands

The Color of Safety Task Force in Pennsylvania did not take a stand on whether color-coded wristbands should be used, but it determined that if you are already using them, you should act to reduce the risk of confusion. The task force recommends risk managers take these steps:

1. Limit the spectrum of color-coded wristbands and standardize the meanings associated with each color. The task force settled on these codes: red = allergy, yellow = fall risk, green = latex allergy, blue = DNR, and pink = restricted extremity.

2. Purchase wristbands with preprinted, embossed text, rather than relying solely on color to communicate the meaning.

3. Avoid handwriting on the band except in emergent situations.

4. Allow only nurses to apply or remove wristbands.

5. If labels or stickers are used in the medical record to communicate the same risk factors as colored wristbands, they must use the same colors and text.

6. Prohibit any nonhealth care wristbands (such as those worn to show support for charities or social causes) in the health care setting. Nurses should remove them (or cover them if patients do not consent to removal) on admission.

Standardization of wristband colors would go a long way toward solving the problem, but Doering says there is no national movement to establish consistent colors. That lack of national consistency creates an obligation for the individual risk manager, he says. "This is an issue that can be addressed in your own organization, but it also is an opportunity to reach out to the providers in your community, perhaps statewide, or throughout a region, to coordinate and create some consistency," he says.

Local efforts make a difference

With no national movement to standardize wristbands, the issue is being addressed with grass roots efforts that will at least provide consistency throughout a region, Doering notes. Like the effort in Pennsylvania, the New Mexico Hospital Association recently addressed the issue with its 41 member hospitals, following survey in January 2007 that found they were using seven colors to designate a DNR and four to indicate allergies. The New Mexico group adopted guidelines from the Western Region Alliance for Patient Safety — a patient safety group that includes health care providers from Arizona, California, Nevada, New Mexico, Oklahoma, and Utah — that are similar to those in Pennsylvania.

Barb Averyt, project director at the Arizona Hospital and Healthcare Association in Phoenix, cautions risk managers against thinking that it is enough to simply declare a certain color code for wristbands in your own facility.

"You may think you have a stable core staff and that if they know what colors you use, then the risk is eliminated," she says. "But it is very common to have nurses that work at two or three facilities at once. You don't know what they're doing on their days off, and that if that other facility uses different colors, you still have the risk of confusion."

In Arizona, about 90% of the hospitals are using the standardized wristband colors, and the rest are moving in that direction, Averyt says. She also points out that education campaigns regarding the wristbands must include a wide range of staff, not just nurses and other clinicians. Housekeeping staff, transporters, and others who have frequent contact with patients also must be included.

"If housekeepers in Arizona see a patient with a yellow wristband trying to get out of bed, they know to immediately tell a nurse and tell the patient to wait for assistance," she says. "Food techs delivering meals can see the red wristband and remember to check for a milk allergy before putting the tray down."

Even with the risk of confusion from wristbands, Averyt says the idea of using color-coded bands still is a valid one. There is some disagreement among health care workers about whether specific information — such as the type of allergy or the initials "DNR" — should be printed on the wristband in addition to using the color. Averyt says the Arizona group favors including the additional wording for clarity and quick access, and the Pennsylvania group concurs. Those who disagree argue that the bands should be used only as a reminder to check the chart, and the text can give a false sense of security about the patient's specific circumstances.

"The wristbands should never replace checking the patient's chart for information, but it can be the first signal that there is a reason for caution," Averyt says. "The idea is to alert staff that there is an issue, and the wristband can be the first step in double checking. But it is never the final word."

Sources/Resource

For more information about color-coded wristbands, contact:

  • Barb Averyt, Project Director, Arizona Hospital and Healthcare Association, 2901 N. Central Ave., Suite 900, Phoenix, AZ 85012-2729. Telephone: (602) 445-4300.
  • Mike Doering, Interim Executive Director, The Pennsylvania Patient Safety Authority, 539 Forum Building, Harrisburg, PA 17120. Telephone: (717) 346-0469.
  • Bonnie Haluska, Associate Vice President, Allied Services Rehabilitation Hospital, 475 Morgan Highway, Scranton, PA18501. Telephone: (570) 348-1300.

The Color of Safety Task Force in Pennsylvania offers a Colored Wrist Band Tool Kit that risk managers can adapt for use in their own facilities. The toolkit includes an implementation and policy manual developed by the task force, a brochure for provider and patient education, presentations that can be used for educating staff and community members, and other materials. Go to www.psa.state.pa.us/psa/cwp/view.asp?a=1293&q=446932. (The tool kit is about halfway down the page.) For a task force report on the safety issues related to color-coded wristbands, go to www.psa.state.pa.us/psa/lib/psa/advisories/v3_s1_sup_advisory_8-9-06.pdf.