Color wristband program seeks to reduce errors

Initiative borrows from earlier programs

The Colorado Foundation for Medical Care (CFMC) and the Colorado Hospital Association (CHA) have partnered to initiate a statewide program that will standardize the colored wristbands worn by patients to indicate allergies, fall risk, and other potential threats to patient safety.

"We use red for an allergy, yellow for fall risk, purple for DNR [do not resuscitate], green for latex allergy, and pink for limited extremity," says Crystal Berumen, MSPH, project director, patient safety initiatives for the Greenwood Village-based CHA.

From Pennsylvania to Arizona…

The wristband concept originated in Pennsylvania, says Berumen, after a swing nurse had tried to put a bracelet on a patient to signify they had a limited extremity (staff were not supposed to use that arm). While the color yellow did mean limited extremity where she had previously worked, at the new facility it meant DNR; the patient arrested, and there was a near-miss.

Subsequently Arizona, which along with Colorado is part of the Western Alliance for Patient Safety (WRAPS), adopted a similar program, changing only the color for DNR from blue to purple. (The reason Arizona did this is in the majority of hospitals in the western region they use the term "code blue" to announce overhead that someone has had a cardiac arrest and needs resuscitation.)

"We and our QIO [CFMC] decided to look at the program last December, and we used the Arizona research and methodology," says Berumen. However, she adds, the Colorado program goes a step further than those in the other states.

"Those other two states said everyone should use a wristband," notes Berumen. "We said they did not necessarily have to use wristbands, but if they used a chart sticker or a placard outside the door they had to make sure the color corresponded with the wristband colors."

"Fundamentally, it's not all about the wristbands but the color — if they want to put a dot on someone's forehead that's up to them," adds Donna Kusuda, RN, MS, CPHQ, vice president, quality improvement & patient safety at HCA Continental Division in Denver. "That did soften the blow; a lot of people did not want to use all these different armbands."

Quality managers take the lead

Kusuda currently serves as the head of a statewide collaborative group of quality managers that was instrumental in formulating the Colorado program. "The Colorado Hospital Association of Quality Professionals is an informal networking organization that we formed about seven years ago because we are a rural state and a lot of quality directors were out there by themselves," she explains. "Since then we have become an advisory body for the CHA board."

The members share e-mails regularly, and meet at least quarterly.

In addition, says Berumen, a teleconferencing option is provided for those members who cannot travel to the meetings — which are usually four or five hours long. "I send out e-mails for quality directors pretty much on a daily basis," she adds.

It was the quality directors, she continues, who initially looked at the project and decided on the colors. "They are also the ones who are implementing the program in the hospitals," she continues. "If they were not engaged and did not have positive opinions about the initiative going through it would have been harder to get buy-in."

How did the group get involved in the initiative? "The CFMC approached us as the hospital body that could perhaps make some decisions and help move the initiative forward," says Kusuda.

Three or four systems in the state were trying to do something similar already, she recalls, so she knew how difficult it would be to achieve consensus. "Just to do this within our system (of seven hospitals) was too narrow in focus," she adds. "When you have competing hospitals across the street using different colors, it does not make sense. Doctors, patients, and nurses go to all these places."

The first thing the group did was to conduct a survey "to see who was doing what and how far off we were," says Kusuda. A lot of time was spent discussing variations among hospitals, and why those variations existed.

"One of our roles was to go back to our constituents and get enough information and input so we could appropriately represent their hospital," says Kusuda. "For example, if we wanted DNR to be purple and theirs was blue, were they willing to change?" In the end, consensus was achieved more quickly than she had anticipated.

"Once they made the recommendation that this was the model they wanted to use, I presented it to the CHA board, and the CEOs of all 25 hospitals made formal recommendations that their facilities adopt it," says Berumen.

Rate of adoption varies

Berumen notes that while some hospitals have already implemented the new program, others are still in the process of adapting it to their unique needs.

"Most people will be on board by the first of the year," she predicts.

"We haven't heard a lot negatives from staff, but [there has been more from] leadership, given all they have on their plates," notes Kusuda. "One system has 16 hospitals that had just implemented a documentation system and wanted to 'settle down' for a while."

One of the more exciting aspects of the program for Berumen is that it will likely continue to expand. "We have received feedback from several hospitals that we should have a color for the bloodbank band," she notes. "I will get all [the quality directors] together on a conference call so they will be on the same page."

Interestingly, the state from which Colorado adapted the program — Arizona — is now waiting to hear what they recommended so they can follow Colorado's lead. "It's important to be aligned with the whole region because a lot of care crosses borders," explains Berumen.

Kusuda says the program will keep patients safer, and make it easier for staff and patients to go from one hospital to another.

There will no doubt be an evaluation of the program "once we get a substantive number of hospitals who have implemented it," she continues, "we'd measure any errors, as well as staff satisfaction, and whether it has been fully implemented."

(Editor's note: The Colorado partnership has released a customized wristband toolkit to all hospital quality directors and CEOs in Colorado. It is available at CFMC's web site: There is a also PowerPoint presentation quality managers can use to train staff, a competency form for staff education, and a patient brochure.)

[For more information, contact:

Crystal Berumen, MSPH, Project Director, Patient Safety Initiatives, Colorado Hospital Association, 7335 E. Orchard Road, Suite 100, Greenwood Village, CO 80111. Phone: (720) 330-6067. Fax: (720) 489-9400.

Donna Kusuda, RN, MS, CPHQ, Vice President, Quality Improvement & Patient Safety, HCA Continental Division, 4900 S. Monaco Street, Suite 380, Denver, CO 80237. Phone: (303) 788-2562. Fax: (303) 779-4993. E-mail:]