By J. Keith Hampton, MSN, APRN, CNS, BC
University of Missouri Health Care
Healthcare providers have long been using color-coded patient wristbands to alert other healthcare providers to certain patient conditions. However, the lack of standardized colors has led to incidents of confusion and error, particularly among healthcare professionals who work in more than one healthcare setting. Without standardization, colored wristbands may pose a serious risk to an organization and patients.
Poor communication is a leading contributing factor to adverse events occurring in healthcare settings, and one way to improve communication is to standardize color-coding for "alert" wristbands within broad geographic areas. Standardized colors and messages displayed on wristbands provide consistent communication within a healthcare setting and between healthcare facilities.
Lack of standardization reveals dangerous consequences
In December 2005, the Pennsylvania Patient Safety Authority issued a patient safety advisory that received national attention. This advisory brought attention to an incident in a Pennsylvania hospital in which clinicians nearly failed to rescue a patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as Do Not Resuscitate (DNR).
The source of confusion was a nurse who incorrectly placed a yellow wristband on the patient. In that hospital, a yellow wristband meant DNR. In a nearby hospital, where the nurse also worked, yellow meant "restricted extremity," which was her intended patient color alert. Fortunately, in this case another nurse recognized the mistake and the patient was resuscitated.
In response to this incident, Pennsylvania hospitals and ambulatory surgery centers were surveyed. The survey revealed 78% of the facilities used color-coded patient wristbands to communicate important medical information, but the meaning of these colors was not consistent among the healthcare facilities.
Pennsylvania became the first state in the nation to implement voluntary guidelines for standardized colored wristbands for six clinical conditions:
- Allergy - red
- Fall risk - yellow
- Latex allergy - green
- DNR - blue
- Patient identification - clear
- Limb alert - pink
The Arizona standard
In response to the Pennsylvania incident, the Arizona Hospital and Healthcare Association surveyed Arizona hospitals. The Arizona survey found 87% of the respondents used colored wristbands, but there was no standardization of colors among them and at least eight different colors were used to designate DNR.
Arizona subsequently standardized the use of colored wristbands, and it chose red for allergies, yellow for fall risk, and purple for DNR. The Arizona standard has been adopted in California, Colorado, Nevada, New Mexico, Utah, and Missouri. In addition to these states, many other states are beginning to assess the use of colored wristbands in the absence of any forthcoming national standard.
The Missouri Center for Patient Safety also conducted a statewide survey of hospitals and nursing homes in the fall of 2006, and 92% of the hospitals that completed the survey indicated the facilities used colored wristbands.
The survey also discovered that 21 different conditions were being indicated by as many as 29 different colors. Many participants in the study used text on their wristbands, and yet even the text varied within the groups. In addition, the majority of facilities did not have a policy addressing the personal wristbands many patients wore before being admitted into the hospital.
Following the Arizona standard, red, yellow, and purple are becoming nationwide standard colors for patient alert wristbands. Red has become a national standard to designate an allergy alert due to research in other industries revealing that red is associated with extreme situations such as "stop" and "danger." Therefore, the color "red" will prompt healthcare providers to "stop" and double check whether or not the patient has a food, medication, or other allergy.
Yellow was selected because other industries recognize yellow as an indication of "caution." According to the American National Standards Institute (ANSI), yellow indicates "tripping of falling hazards." Thus, yellow fits well as a healthcare indicator of a fall risk because it will alert providers to look out for patient conditions such as a history of falls, dizziness, balance problems, or confusion.
The purple discussion proved more complex. Healthcare facilities use the term "code blue" to activate the resuscitation team, thus the initial dialogue was to use blue for the DNR bands. However, many respondents felt blue would confuse the resuscitation team since it would indicate the patient should be resuscitated. To prevent second-guessing and confusion, purple was chosen to indicate DNR.
When seconds count, a color-specific alert wristband will quickly communicate a patient's status in a crisis, during an evacuation situation, or while in transit between healthcare facilities.
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