YOUR PATIENT Mary Jones, 82, is transferred from a long-term-care (LTC) facility to a medical unit for treatment of pneumonia. She has a history of a stroke with left-sided hemiparesis, and she had a left mastectomy 15 years ago. She's allergic to penicillin and latex. Her admitting orders include a do-not-resuscitate (DNR) order.
On your initial assessment, you note that Mrs. Jones is wearing wristbands in five different colors, plus a black-and-white ID wristband. When you begin to remove all the wristbands, Mrs. Jones objects, saying, "They told me all these wristbands are important."
Explaining that your facility uses a different color code system, you tell her you'll be giving her a new set of wristbands. Mrs. Jones asks, "Why don't you all just use the same color scheme?"
We think Mrs. Jones has an excellent idea. In fact, a national movement to standardize the color-coded wristbands used in healthcare is underway to help prevent confusion and increase patient safety. This article explains the dangers of using nonstandardized color-coded wristbands and suggestions for using colored wristbands safely.
The first red flag
The patient safety issues of color-coded wristbands first gained widespread attention when a Patient Safety Advisory was issued by the Pennsylvania Patient Safety Authority (PA-PSA) in 2005. It was based on a report received by the Pennsylvania Patient Safety Reporting System. A patient experiencing a cardiopulmonary arrest almost wasn't rescued because the patient had mistakenly been given a yellow wristband, which signified a DNR order. The nurse who had placed the yellow wristband on the patient also worked at another hospital in the area where yellow meant "restricted extremity." Fortunately, the mistake was recognized in time and the patient was resuscitated.1
Pennsylvania is unique in the nation in that a near-miss such as this, which resulted in no patient harm, is a mandatory reportable event.2 The report brought to light a problem that wasn't being discussed and stimulated an investigation to determine the scope of the risk to patient safety.
Staff at the Pennsylvania Patient Safety Reporting System proceeded to survey all hospitals and ambulatory surgical facilities in Pennsylvania about their use of color-coded wristbands. They found that healthcare facilities were using nine different colors of wristbands communicating 22 different messages. Colors and messages differed among all the facilities, indicating no standardization. A DNR order was indicated by five colors, fall risk by eight, restricted extremity by eight, and allergy by seven.1
Pennsylvania formed a task force of 11 hospitals to develop a model for safe practice in the use of color-coded wristbands.
Other states weigh in
A survey completed in Missouri hospitals and LTC facilities identified 29 colors being used to communicate 21 clinical conditions. Again there was no standardization, with the wide diversity of colors used to communicate patient information via wristbands raising a red flag for patient safety.3
Other states also reported issues. The Colorado Foundation for Medical Care surveyed Colorado hospitals and found various colored wristbands in use, again with no standardization.4
The Arizona Hospital and Healthcare Association (AZHHA) surveyed hospitals in Arizona in March 2006 and found a total of eight different colors or methods in use to convey DNR. To further compound the problem, every hospital in Arizona reported using registry or travel nurses to staff vacant positions.5 As a solution, the AZHHA developed a standard system of color-coded wristbands and recommended its use by all Arizona hospitals.
Although Pennsylvania and Arizona have been proactive in standardizing color-coded wristbands in their own healthcare systems, at first their standards didn't match. The two states initially used different colors, purple and blue, to indicate DNR. Pennsylvania changed from blue to purple because of concerns that blue wristbands could cause confusion with a code blue. (See Color me safe: Recommended standardized wristbands.)
Colorado, Minnesota, and other states are adopting or considering adopting this color code. (See Access these states' toolkits.) Around 35 states now have some form of standardized color-coded wristbands.6
Now that we understood the issue, we decided to do our own survey of LTC facilities in Arizona.
Performing our survey
Almost everything we found in the literature addressed wristbands in acute care settings, but we often saw patients admitted from LTC facilities wearing colored wristbands. We wondered how LTC facilities were using color-coded wristbands and whether they also lacked standardization. We developed a short survey and obtained the approval of our Institutional Review Board to conduct the survey.
In January 2008, we mailed the survey to the attention of the directors of nursing at all 166 LTC facilities in Arizona. Sixty-two usable surveys were obtained for a response rate of 37%. The responses came from various facilities, but those with 101 to 200 beds accounted for 58% of responses. About a third of the facilities identified themselves as urban and for profit.
Half of the facilities indicated they currently use a color-coded wristband system. We found that LTC facilities, just like hospitals in several states, lacked a standard color-code system.
In our survey's cover letter, we had briefly described the Pennsylvania incident and the AZHHA recommendation that a standard system be developed. We asked, "Would you be willing to consider changing your current color-coded wristband system in order to implement a voluntary national standard?" Eighty-two percent indicated willingness to consider adopting a national standard.
The final question invited respondents to relate examples of problems stemming from confusion about wristband colors in their facility as well as any other concerns or suggestions. Three respondents stated they don't use color-coded wristbands due to concerns that doing so would violate privacy provisions in the Health Insurance Portability and Accountability Act.
One director of nursing wrote that she'd wanted to implement the standard system but the administration told her she couldn't due to concerns about residents' rights. To find out more, we asked a representative of The Joint Commission if color-coded wristbands are allowed. She said "The Joint Commission does not prohibit wristband color-coding systems."
Other concerns expressed by survey respondents included the possibility of bracelets causing skin tears, being removed by confused residents, falling off, or not being updated by staff.
Some respondents who don't use a color-coded wristband system said their intent is to ensure that staff looks at the medical record for important information, such as allergies and DNR orders. This reasoning has a valid foundation. Wristbands should never be relied upon instead of the patient's medical record. In fact, in the Patient Safety Advisory in 2005, the PA-PSA described a separate incident in which a patient with a DNR order had been mistakenly resuscitated because the wristband ordered by the healthcare provider hadn't been applied.1
One survey respondent shared a recent incident in which an employee was unsure of a resident's code status and started CPR only after going back to the desk to check the medical record. This delayed the arrival of the code team, but fortunately, the resident survived.
We had hesitated to include a question inviting respondents to discuss mistakes in their facilities because we were worried that it might lower the response rate even though the survey was anonymous. We considered it important to ask because we agree with one patient safety director who said, "If it's happened other places, it's happened here."7
Based on the findings from this small study, we learned that lack of standardization of color-coded wristbands is problematic in LTC facilities as well as in the acute care setting. Many nurses have heard of mistakes related to confusion about a patient's DNR status, although nobody wants to talk about it. But such mistakes must be brought out into the open so that we can learn from them and prevent them in the future.
Forming our recommendations
The standardization of wristband colors needs to continue nationwide. The FDA has endorsed several of the recommendations made by the Institute for Safe Medication Practice and the PA-PSA:
- "Limit the number of colors used on patient wristbands.
- Use only primary and secondary colors. Don't use shades of the same color to convey different messages.
- Use wristbands preprinted with text explaining what the band means—a big help for new clinicians and for all caregivers who are color blind or working under dim lights.
- Remove or cover with a bandage or medical tape any nonmedical colored wristbands that patients may be wearing when they present to a facility.
- To provide an additional safety check, explain to patients and family members the purpose of color-coded wristband usage."8
We propose that all states adopt a national standard. Nursing shortages and economic conditions lead many nurses to work overtime or a second job. Travel nurses work on temporary assignments in many locations all across the country. This, combined with the wide variety of color-coded wristband systems in use, is a recipe for confusion. Change is never easy, but we were able to effect change in our facility. (See Making the switch without a hitch.)
State health departments, nursing organizations, risk managers, administrators, The Joint Commission, and staff nurses should all encourage standardization. We recommend the five-color system used by Pennsylvania, Colorado, and Minnesota. We encourage you to discuss this idea with colleagues and supervisors. By being patient advocates, we can help prevent mistakes.
Making the switch without a hitch
Change to a national standard won't come quickly or easily, but the Veterans Affairs (VA) system, the largest healthcare organization in the country, is in an excellent position to lead the way. The VA Medical Center in Phoenix, Ariz., has adopted the colors recommended by the AZHHA. Staff development sessions for the nursing staff about the Pennsylvania incident and the movement toward standardization helped the staff accept the need to switch our wristband colors. The change was accomplished over a weekend without a hitch.