The Color of Safety

Indiana Hospital AssociationColor-coded Wristband Alert Standard

Impetus for Standardization• Pennsylvania – wrong color Do Not Resuscitate band

applied by nurse who works in two different hospitals with two

different protocols

• Multiple states initiated standardization efforts over past

several years.

• American Hospital Association issued advisory on September

4, 2008 recommending standardization to 3 colors –

• Red for allergies

• Yellow for falls risk

• Purple for DNR

Background• December 2005

– Pennsylvania Patient Safety Authority (PSA) released an

advisory about a recent “near-miss” report involving

confusion caused by color coded patient wristbands

– Clinicians almost failed to resuscitate a patient in

cardiopulmonary arrest because that patient was

incorrectly designated as Do Not Resuscitate (DNR)

Source: Pennsylvania Patient Safety Reporting System (PA-PSRS). Color-coded patient wristbands create unnecessary risk. Supplementary Advisory. 14 Dec

2005;2(S2):1-4.

Background (cont.)• Lack of consistency in the meaning of color coded patient

wristbands problematic:

– Patients being transferred among hospitals

– Patients under the care of clinicians who work in multiple

hospitals

• Pennsylvania case

– Mistake quickly realized and patient was rescued

National Survey• American Society for Healthcare Risk Management (ASHRM):

– Leader in wristband color coding national initiative

– Nation-wide survey in 2007

• 50 states

• 4 others (e.g. D.C. & Military Health Services)

– 100% response rate

Source: American Society for Healthcare Risk Management (ASHRM). Color Coding Wristbands: A Nationwide Practice Survey.

National Survey (cont.)• Survey results:

– 60% of the survey population:

• Actively discussing

• Developed/developing a model, or

• Have adopted existing model

– Color coded wristbands are used most frequently for DNR,

Allergy and Fall Risk categories

National Survey (cont.)• Allergy

– National color acceptance of RED

• Fall Risk– National color acceptance of YELLOW

• DNR– Most variation (e.g. PURPLE & BLUE)

• Restricted Limbs– Moderate color acceptance of PINK

• Latex Allergy– Moderate color acceptance of GREEN

Indiana Survey• 2/08

– Surveys sent out to Patient Safety Officers and Chief Nursing

Executives

• 93 hospitals responded

• 73.6% of hospitals use color coded patient wristbands

• 72.9% of hospitals do not emboss or imprint the risk/condition

on the band

Indiana Survey Summary• Significant variation in Indiana hospitals regarding use of color

coded patient wristbands:

– DNR and Fall Risk represented 9 ways

– 39% use red for Allergy

– Latex Allergy represented 10 ways

– 69% use no bands for Restricted Extremity

– 74% use white bands for Patient ID

Indiana Hospital Association Action• Council on Quality and Patient Safety

– Discussed issues related to lack of national or state standard on the

use of wristband colors at February 2008 meeting

– Council recommended delaying action until national

recommendations were available

– Sent a recommendation to the IHA Board of Directors for wristband

standardization in Indiana in September 2008 after AHA advisory

released

• IHA Board of Directors

– Approved a resolution and Council recommendations in November

2008

Assessment of Current Environment• Patient safety is a key focus in all Indiana health care facilities

• Significant variation exists in hospitals

• Confusion with social cause wristbands

• Health care staffing and patient movement

– Physicians and staff working at multiple organizations

– Agency nurses and other staff

– Multiple state system hospitals and hospitals near state borders

– Patient transfers

• Human factors research supports standardization

Standardization by State 2/09KEY

Implemented at least 2-5 standard colors

Standardizing in 2009

No standardization or

plan of standardization

Summary• Safety is a key priority for Indiana health care organizations

– Near misses have been reported in other states

– Many Indiana systems/regions are interested in standardizing

communication about patient information and risks

• Not all Indiana hospitals use color as a safety alert

• For hospitals that do use color as a safety alert, there is

significant variation

• Many of our neighboring states have already adopted or are

considering wristband color standards

Indiana Hospital AssociationRecommendation

The Board of Directors of the Indiana Hospital Association recommends that

all hospitals evaluate methods to effectively communicate patient information

and risks. The use of wristband colors for patient alerts is not required, but If

an organization elects to use color-coded alerts to communicate patient

information or risks, the Association encourages Indiana hospitals to use the

following colors:

RED ALLERGY

GREEN LATEX ALLERGY

YELLOW FALL RISK

PURPLE DO NOT RESUSCITATE

WHITE PATIENT IDENTIFICATION

PINK LIMB ALERT/RESTRICTED EXTREMITY

Red - AllergyRecommendation:

It is recommended that if a hospital chooses to use a color to designate patient allergies, that it adopt the color of

RED for the Allergy designation with the word “Allergy” embossed/printed on the alert. Hospitals should develop

a consistent process for indicating specific allergy (i.e. – note all allergies in the medical record).

Q. Do we write the allergies on the alert too?

A. It is recommended that allergies be written in the medical record according to your hospital’s policy and procedure and

should not be written on the alert for several reasons:

– Legibility may hinder the correct interpretation of the allergy listed.

– By writing allergies on the alert someone may assume the list is comprehensive. However, space is limited on an

alert and some patients have multiple allergies. The risk is that some allergies would be inadvertently omitted—

leading to confusion or missing an allergy. By having one source of information to refer to, such as the medical

record, staff of all disciplines will know where to find a complete list of allergies.

– Throughout a hospitalization, allergies may be discovered by clinicians such as dieticians, radiologists, pharmacists,

etc. This information is typically added to the medical record and not always to the alert. By having one source of

information to refer to, such as the medical record, staff of all disciplines will know where to add newly discovered

allergies.

Green – Latex AllergyRecommendation:

It is recommended that if a hospital chooses to use a color to designate latex as a specific allergy, that

it adopt the color of GREEN for the Latex Allergy designation with the letters “Latex Allergy”

embossed/printed on the alert.

Q. Why should we use wristbands for latex allergy alerts?

A. Many products used in hospitals are made of latex and can cause certain patients to have a

severe allergic reaction. When a patient is wearing this wristband it alerts hospital staff that

they have allergies to products containing latex and non-latex supplies should be used.

Q. Can our hospital use a red alert band to designate all types of allergies?

R. Yes. It is not mandatory for a hospital to adopt any color wristband to designate patient

alerts. Some hospitals may find a benefit in adopting a separate color for latex allergies, in

which case, we recommend green. Otherwise, a red band is sufficient with the specific type

of allergy noted in the medical record.

Yellow - Fall RiskRecommendation:

It is recommended that if a hospital chooses to use a color to designate falls risk that it adopt the color of

YELLOW for the Fall Risk designation with the words “Fall Risk” embossed/written on the alert.

Q. Why did you select Yellow?

A. Research of other industries tells us that yellow has an association that implies “Caution!” Think of traffic lights: yellow lights

mean proceed with caution or stop altogether. The American National Standards Institute (ANSI) has designated certain colors

with very specific warnings. ANSI uses yellow to communicate “Tripping or Falling hazards.” This fits well in healthcare when

associated with a Fall Risk. Caregivers want to know to be on alert and use caution with a person who has history of previous

falls, dizziness or balance problems, fatigability, or confusion about their current surroundings.

Q. Why even use an alert for Fall Risk?

A. According to the Centers for Disease Control and Prevention (CDC), falls are an area of great concern in the aging population.

– More than a third of adults age 65 years or older fall each year.

– Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes.

– Of those who fall, 20% to 30% suffer moderate to severe injuries that reduce mobility and independence, and increase the risk of

premature death.

Purple - DNRRecommendation:

It is recommended that if a hospital chooses to use a color to designate a patient’s preferences for end-

of-life care associated with DNR status that it adopt the color of PURPLE for the Do Not Resuscitate

designation with the letters “DNR” embossed/printed on the alert.

Q. Should we use wristbands for DNR designation?

A. While there is much discussion regarding the issue of “to band or not to band,” a literature review to date has not conclusively

identified a better intervention in an emergency situation. One may say, “In the good old days we just looked at the chart and

didn’t band patients at all.” However, those days consisted of a work-force that was largely employed by the hospital. Today, an

increasing number of healthcare providers working in hospitals are not hospital-based staff or work for more than one facility.

Travel staff may not be as familiar with how to access information (as in the use of computerized medical records) or may not

be familiar with where to find information in the medical record. When seconds count, as in a code situation, having a wristband

on the patient is one way to improve communication and reduce the risk of an error.

Q. Why not use Blue?

A. At first, blue was considered a great color choice. However, many hospitals utilize “Code Blue” to summon the resuscitation

team. By also having blue as the DNR alert color, there is the potential to create confusion. “Does blue mean we code or do not

code?” To avoid creating any second guesses in this critical moment, we opted to not use blue.

Pink – Limb Alert/Restricted ExtremityRecommendation:

It is recommended that if a hospital chooses to use a color to designate restricted extremity that it adopt the color of PINK for the Limb Alert designation with the letters “Limb Alert” embossed/printed

on the alert.

Q. Why should we use wristbands for limb alerts?

A. Some patients have conditions that restrict the use of a certain arm or leg. Patients with this

condition wear a pink band on the affected extremity to alert staff to avoid using this limb for

blood draws, IV insertions, and other medical procedures.

IHA Council on Quality & Patient Safety Recommendation

• Hospitals that do not use color alerts should consider whether the standardized colored wrist

bands are the best solution for their hospital

• Hospitals using color alerts (wristbands, stickers, etc.) are encouraged to use the Indiana

standard to improve communication

• Other color alerts based on hospital choice– Limit additional alerts to only those needed– Use only primary and secondary colors; avoid shades of colors

• Select wristbands with preprinted text– Do not write allergies or other patient specific information on wristbands except for patient

identification

• Engage the patient and their family in a dialog to identify risk– Request patients remove colored social cause wristbands

RED ALLERGY

GREEN LATEX ALLERGY

YELLOW FALL RISK

PURPLE DO NOT RESUSCITATE

WHITE PATIENT IDENTIFICATION

PINK LIMB ALERT/RESTRICTED EXTREMITY

 Toolbox• Contents

– Voluntary Indiana color-coded alert standards manual – Sample policy– Sample staff education brochure– Sample staff competency check list– Sample project plan– Sample patient education brochure

• Distribution– Electronic notice sent to each hospital

• Nursing• Quality

• Communication– Organizational newsletters & Website

Timeline & Tracking• Goal: 100% voluntary use of Indiana standard colors by

December 31, 2009 for hospitals using color-coded wristband

alerts

• Notify IHA by contacting Mikell Brown at mbrown@ihaconnect.org

when you have converted to the standardized wristband colors

AcknowledgementsIn the spirit of sharing best practices for improvement, many sources contributed to the background

and materials for this implementation toolkit. The Indiana Hospital Association and the Indiana

Patient Safety Center gratefully acknowledge the following organizations and individuals:

•The Pennsylvania Color of Safety Task Force, which developed the initial policy regarding

wristband color standardization.

•The Arizona Hospital and Healthcare Association for their work to develop the initial

implementation toolkit.

•The Wisconsin Hospital Association (WHA), whose adaptation of the toolkit was modified for use

in Indiana. Particular thanks go to Dana Richardson at WHA for granting permission for the use of

their work.

•Special thanks to Jessica Langlois, Ashley Canon, Madilyn Moran, and Sarah Goranovich, BSN

students at the Purdue University Calumet School of Nursing, for providing materials which were

also adapted for this toolkit.

 

Direct questions toBetsy Lee, RN, MSPH

Director, Indiana Patient Safety Centerblee@ihaconnect.org

317-423-7795