Ambulatory Care Quarterly

Initiative sparked by close call with DNR wristband

Effort has implications for access

A "near-miss" in which a nurse at a Pennsylvania hospital incorrectly placed a "do not resuscitate" (DNR) wristband on a patient has prompted an Ohio initiative aimed at implementing statewide standardization of colored wristbands.

Based on the Pennsylvania incident — which occurred because the nurse worked at multiple hospitals that used different-colored bands to designate a DNR order — an Ohio task force looked at how the process was handled by that state's providers, says Rosalie Weakland, director of quality improvement for the Ohio Hospital Association (OHA). Fortunately, she notes, another nurse at the Pennsylvania facility caught the mistake just in time to resuscitate the patient.

In surveying Ohio providers, she adds, "we found 19 different colors [for wristbands], with 28 different meanings. Sometimes the same color was used for two things. For example, emergency department patients had yellow wristbands, and then when they became inpatients, a yellow wristband was for a person who was at high risk for a fall."

The task force, convened by the Ohio Patient Safety Institute (OPSI), set an ultimate goal of eliminating all wristbands except those used for patient identification, in favor of electronic tracking systems, Weakland says. But because many providers are not ready for that step, she adds, an interim goal of standardizing and reducing the colors used for wristbands to four was established.

The OPSI now recommends that all Ohio providers adopt the following standard wristbands: 1) white/clear for patient identification; 2) red for a known allergy; 3) yellow for a high fall risk; and 4) green for blood products (if a patient is supposed to get platelets or a unit of blood).

A national standard

"My ultimate mission is a national standard," Weakland notes. "Health care professionals go across the nation and, depending on locations, hospitals transfer patients across state borders." Different colors between states can lead to problems, "so we're trying to get our bordering states to have consistent colors."

The first thing you can do regarding the issue, she suggests, "is try to promote a standardized wristband for patient identification. I personally recommend that all [providers] go with white in all locations — ED and ambulatory surgery, for example — not just for inpatients."

Depending on the setting, staff could potentially also look at DNR wristbands, Weakland says, "because a lot of registrars ask [about DNR instructions] as an initial question. If that is the case, be aware of the [type of] wristband that is appropriate for their state."

Some registrars also are in the position of asking about patient allergies, she says, in which case they should be aware of the appropriate wristband for that condition. "Red tends to be the wristband color for [allergies] across the country, DNR is mostly purple, and yellow is consistent for fall risk."

Some states, however, use colors differently, Weakland says, including many that indicate the need for blood products with a red wristband. Ohio is the only state that is required by law to indicate a DNR order with white paper inside of a clear wristband, she points out.

State activists hope to get that law changed, Weakland adds, and because it is under review, the task force is not making a recommendation regarding DNR wristbands at this time.

The contention of the Ohio task force — which comprises representatives from hospitals, home health agencies, ambulatory facilities, and hospice organizations — is that the number of different wristbands used should be limited to four in order to avoid confusion, she explains.

Some hospitals use additional wristbands to indicate things such as which side of the body is scheduled to receive surgery or that a particular limb should not be used to draw blood, Weakland says, but her belief is that having too many increases the chance of error.

"The fewer the better," she says. "These [four] are the high-volume ones. If we [replace the bands with] technology, the fewer we have to delete, the better."

While leading-edge hospitals at present are moving toward bar coding as the alternative to banding, Weakland notes, "technology changes so fast that there may be something additional that will be used."

Another task force recommendation that relates to registration personnel, she adds, is that patients remove community wristbands such as the "Live Strong" band inspired by Lance Armstrong during their hospital stay.

Access staff should "start sending that message during registration," Weakland suggests. "In an emergency, even though those bands are made from different materials, you could have confusion. Encourage patients to remove [community wristbands] and send them home, or save them until after discharge."

(Editor's note: More information is available at www.ohiopatientsafety.org. Rosalie Weakland can be reached at rosaliew@ohanet.org.)