In several of our Tips of the Week we have mentioned issues related to the use of colored-coded labels or identifiers to alert staff to a number of issues (high alert medications, flag catheters, flag orders, etc.). Visual cues are a time-honored way of communicating information of extreme importance. However, lack of standardization of colors and their meanings can lead to dangerous circumstances and produce undesired outcomes.
An advisory by the Pennsylvania Patient Safety Authority in December 2005 was inspired by a near-miss incident in which a patient incorrectly had a yellow-colored wrist band placed that meant “Do Not Rescuscitate”. The nurse who placed the yellow wrist band usually worked in another facility where a yellow wristband meant “restricted extremity”. The advisory gave several other examples of incidents arising from color-coded wrist bands and also noted that wristbands are often temporarily removed for procedures or may be covered up by the patient or a caregiver and that some patients may come into a hospital wearing a colored wristband that has nothing to do with their health status (eg. social cause wristbands). The PSA then did a statewide survey and found that most facilities used color-coded wrist bands to indicate at least some condition or alert but that lack of standardization across facilities (for both the colors used and the conditions for which they are used) was a major problem. They made several recommendations:
They also recommended addressing the issue of wristbands that patients bring with them on admission, patient/family/staff education, policies and procedures, etc.
The issue of standardization remains the most significant barrier to use of color-coded wristbands as a patient safety tool. Several states and regions have done collaboratives to adopt standardized practices on this issue. The Missouri Center for Patient Safety recently put out an excellent toolkit "Banding Together - for patient safety" Standardization and Implementation Toolkit”.
They adopted most of the recommendations from the Pennsylvania PSA and recommended only three colored wrist bands: red to denote allergies, yellow to denote high fall risk, and purple to denote DNR. They chose red for allergy because red signals “Stop!” in most industries and other environments. Yellow was chosen for fall prone patients since it denotes “Caution!”. Purple was chosen to denote that a patient has “Do Not Rescuscitate” status, largely because blue (currently used at many hospitals) might lead to confusion. Since “Code Blue” is used by many hospitals to summon the rescuscitation team, a blue wristband might confuse people as to whether blue means “do I code or not code here?”. They also recommend pre-printing text on the bands to help reinforce the color-coding system for new staff and to help avoid confusion in dim light or for color blind individuals.
They recommend removal of any “social cause” or other colored wristbands on admission (with appropriate education of patients and families of the reasons) and, if that is not possible, covering those wristbands with bandages or medical tape. And wristbands from other facilities should be removed.
The Missouri toolkit has excellent resources for implementation, including good tips about development of policy and procedure, a sample workplan, FAQ’s, staff education, patient/family education, community education, brochures, PowerPoint slides, and even references on makers and designs of wristbands.
We highly recommend use of color-coded wristbands for the above indications, but only when you can be reasonably sure that all healthcare workers who might be working in your facility fully understand their meaning and use. That usually means that there has been a regional or state-wide collaborative to standardize the colors and their meanings across healthcare sites. We see many such regional organizations looking for a good project to collaborate on. This is a good one and most of the leg work has already been done for you!
The Colorado Foundation for Medical Care also provides a Wristband Color Standardization Project Implementation Toolkit. They add the color green to denote latex allergy and the color pink to denote restricted extremity. They also thoughtfully recommend that the color designation should apply not only to wristbands but any form of designation of the 5 conditions (eg. stickers or placards).
The Minnesota Hospital Association also has a Wristband Implementation Toolkit. It also adopts green to denote latex allergy and pink to denote restricted extremity. They also provide a Power Point presentation on the color-coded wristbands and a sample policy.
Update: See October 2008 What’s New in the Patient Safety World “More on Color-Coded Wristbands”