Color Coded Patient Safety

Written By:
Paulette Campbell RN-BC, BSN, MJ
Certified Legal Nurse Consultant

In an effort to increase patient safety, many hospitals all across the county initiated color coded wrist bands. These wrist bands give healthcare team members the ability to know key information about a patient at a glance. Some of the benefits of this patient safety initiative are;

• For emergent situations, when healthcare team members are called into a patient’s room where they would not have had access to the patient’s medical history (the band would tell about diabetic status or DNR status)
• For those times when patients are transferred to other areas of the hospital, they would have immediate knowledge about significant patient information such as latex allergy, fall risk, etc.

As this safety initiative advanced, what was found is that there are lots of different reasons to use the safety colored bands. Some of those reasons include;

• Drug Allergy
• Fall Risk
• Same Name Alert
• Bleeding Risk
• Wandering/Elopement Risk
• Contact Isolation
• Latex Allergy
• No Blood Draws on Particular Extremity
• MRSA Infection
• No Blood Products
• Sleep Apnea
• Procedure Sit
• Pediatrics/Mother Match
• Pacemaker
• Anticoagulant
• Diabetes

However, problems have developed with these well-intentioned initiatives. Some of these problems have occurred when patients have been transferred to different facilities and the separate hospitals have had different meanings to each of the wristband colors. One of the most reported issues with this type of patient safety near miss is a patient who is transferred with a band color that indicates “Fall Risk” at the first hospital but at the second hospital means “Do Not Resuscitate”.

There have also been reports related to travel nurses who were used to band colors having different meanings. One report indicated that a nurse placed a yellow band on the patient because at her regular facility it indicated restricted extremity. However, at the facility she was working at that day the yellow band color indicated “Do Not Resuscitate”. The patient arrested; however, the incorrect band color was quickly corrected.

In December of 2004, a Florida hospital that used yellow wrist bands had several near misses because of the Lance Armstrong Live Strong wristbands. In an effort to eliminate devastating circumstances that could occur over such confusion, many hospitals removed those wristbands from patients on admission.

A study was done to look at how the “Do Not Resuscitate” status is communicated at various healthcare institutions and the approach to the DNR status of patients. One of the findings from the study was that 55% of hospitals use color coded wristbands with the most common uses for allergies, fall risk, and same last name alert. The study also found twelve different indications were depicted by various colors. There was great variation in color choices for given indication and across the different indications.

The National Patient Safety Agency found 2,900 reports of patients being mismatched to their care related to wristbands and their use. Many patient safety advocates have called for wristband color standardization throughout the county. Currently, fourteen states have standardized color coding alerts. Other states including; Illinois, Indiana, Michigan are reviewing such options for their states.

The Institute of Safe Medicine Practice has made the following recommendations;

• Limit the Number of Choices
• Use Reminders (in addition to color coding bands and descriptive text on the band)

For more information about Color Coded Patient Bands, contact us. If you have medical legal consulting needs such as researching current standards of care or identifying any adherence or deviations for your legal practice, contact our medical legal consulting office at info@medicaljurisprudence.com or 630-551-0978.