State task force develops protocols for wristbands
State task force develops protocols for wristbands
Protocols and toolkit are available online
A task force of 11 Pennsylvania hospitals has developed a set of detailed protocols to reduce the risk of medical error when using color-coded patient wristbands. The protocols and a toolkit to help health care providers and facility managers implement them are available on the web site of the Pennsylvania Patient Safety Authority (PSA) (www.psa.state.pa.us/psa/site/default.asp).
The task force was established after the Pennsylvania Patient Safety Reporting System (PA-PSRS) received a report in which clinicians nearly failed to resuscitate a patient who was incorrectly designated as a DNR. A nurse incorrectly placed a yellow wristband on the patient. (In that hospital, the color signified DNR.) The nurse had worked at another hospital, in which yellow signified "restricted extremity" — i.e., not to be used for phlebotomy or IV access.
More than 450 Pennsylvania hospitals, ambulatory surgery centers, and birthing centers are required to report to the PSA any patient-related adverse events or near misses.
"The nurse in question did not deploy a rapid response or a code team because of her interpretation of the wristband color," adds Fran Charney, RN, patient safety officer and director of risk management at Holy Spirit Health System, Camp Hill, and a task force participant.
(Task force members include Allied Services Rehabilitation Hospital, Community Medical Center, Holy Spirit Health System, John Heinz Institute, Marian Community Hospital, Mercy Hospital, Mid-Valley Hospital, Moses Taylor Hospital, Pocono Medical Center, Tyler Memorial Hospital, and Wayne Memorial Hospital.)
"The PSA trends reporting of health care facilities and had an advisory issued in mid-December of last year," Charney says.
Assessing the situation
Following the advisory, PA-PSRS surveyed the patient safety officers of all Pennsylvania hospitals and ambulatory facilities to determine how many used color-coded wristbands and what the different colors meant. (One-third of the hospitals — 139 — responded.) "In that survey, over 80% said they used colored wristbands, and almost all of them used different colors to represent different critical need-to-know items," says Charney.
At Holy Spirit, Charney's team conducted an FMEA (Failure Mode Effects Analysis) "to take a proactive look at how to make the institution safer without such an event ever occurring and how to assure that if a nurse comes here from 'hospital A' they will now know what our colors mean," says Charney.
What the team came up with was a "backup system" that involved printing the meaning of the wristband color on the band itself. "Now, if a nurse comes from another hospital, she will clearly know that a red armband here means allergy, because it is printed on the band," Charney explains.
Standardization
The different color codes are also part of the orientation process, "But as you know there is saturation [of information], and if I have 20 years at another hospital and am now a newbie here, I have it actually written on the armband in case I have forgotten," Charney says.
In addition, a group of hospitals in the northeastern part of Pennsylvania have begun an effort to try to standardize what colors mean within the commonwealth. "There is no legislation — it's all voluntary — but 13 hospitals hope it will be in place by the beginning of next year," says Charney. "The system is finished, and we have presented it to the PSA."
Charney says that even with such a uniform code, the dual system employed at Holy Spirit would still be "absolutely necessary."
Even if there were a uniform system, she notes, "there are nurses with color blindness and other vision problems," she explains. "Having two indicators is just a good patient safety practice."
After receiving input from the task force, the PA-PSRS has posted on its web site the following risk reduction strategies:
- Limit the number of wristbands in use.
- Use only primary and secondary colors.
- Standardize the meanings of specific colors among health care facilities.
- Use brief, pre-printed descriptive text on wristbands.
- Educate patients/families of the purpose of all wristbands applied.
- Remove colored wristbands supporting community campaigns when patients present to the facility.
- Integrate wristband verification into change-of-shift nursing assessment.
- Develop policies/procedures defining wristband responsibility and authority to place wristbands on patients.
- Consider potential confusion between Broselow color-coding system for pediatric resuscitation and colored wristbands used in the facility.
What has most impressed Charney is the way that the different hospitals have come together, sharing information and recommendations. "I think it's significant that everyone is participating," she says. "The way we view patient safety has changed tremendously; something starts with one phone call and it just grows into a commonwealth-wide initiative."
For more information, contact:
Fran Charney, RN, patient safety officer and director of risk management, Holy Spirit Health System, 503 North 21st St., Camp Hill, PA 17011. Phone: (717) 763-3059. E-mail: [email protected].
A task force of 11 Pennsylvania hospitals has developed a set of detailed protocols to reduce the risk of medical error when using color-coded patient wristbands. The protocols and a toolkit to help health care providers and facility managers implement them are available on the web site of the Pennsylvania Patient Safety Authority (PSA) (www.psa.state.pa.us/psa/site/default.asp).Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.