In case the reader needs reminding, risk management professionals make a phenomenal team when they unite to protect patients against risk. A special team effort to protect patients from an incipient risk began in late 2005 when a risk manager at a Princeton-insured facility voiced a concern that perhaps too many colored wrist bands were being used in individual facilities. Her concern was that the multiplicity of colored bands might lead to confusion in staff responses; but soon an even greater worry surfaced.
A request for input on the original question was sent out to all Princeton-insured facilities; many responses were received. One reply raised a new and more disturbing question: what happens when patients from one facility are transferred with their bands still on to another institution which also uses colored wrist bands, but the colors at the new facility mean something totally different? This had already happened to this organization and potential errors had been caught in time. Policies and procedures had been put in place, staff had been trained, yet patients were still being transferred in from other facilities wearing their colored bands. The risk was under better control at this facility, but what about all the others?
To conceptualize this concern in specific terms, consider the following questions: what if your facility uses a yellow band to denote a fall risk and you send your patient, with that wristband still on, for daily rehabilitation to a facility where the band-color-coding policy says that yellow means “Do Not Resuscitate” (DNR)? The potential error in this circumstance is very serious. The potential for errors does not exist just between healthcare facilities either. What if a patient was admitted to your facility already wearing their own yellow wristband? That patient might be supporting a boycott of Aruba, or recognizing the Gulf War, or the Spina Bifida cause. The Web site for Know More Wristbands lists twenty-five different causes or issues for yellow wristbands. In fact, they offer wristbands for purchase in thirty-one colors, with lists of the causes and issues that each color, or combination of colors, represents. They also explain which conditions or issues have alternate colors for easy reference. Their Web site is www.personalizedcause.com.
As soon as Princeton risk management was made aware of this potential threat to patient safety, client hospitals were contacted and Aline M. Holmes, RN, APNC, MSN, Senior Vice President, Clinical Affairs of NJHA was made aware. Three months later, an alert was posted on the Pennsylvania Patient Safety Authority Web site. A Pennsylvania hospital had suffered a near-miss when a patient who suffered a cardiac arrest almost was not resuscitated. The patient’s color-coded wristband, which meant DNR at that hospital, was put on in error by a nurse who worked in two facilities where the color-coding was different. She used the coding from the other institution where she worked when she gave this patient his wristband. Aline forwarded this alert to all New Jersey hospitals for comment.
The NJHA ListServe received a number of replies which varied in their position on the subject of the wristbands. Some facilities were using bands which were not only colored, but had an imprint of what the color meant. Others discussed the idea of standardizing the color coding of wrist bands state-wide. Some were opposed to the very idea of color-coded wrist bands and wanted all staff to use only patient information from medical records on which to base their decisions. After this comment was made, the matter continued to be reviewed in the NJHA Quality Improvement Advisory Meetings. According to Aline Holmes, the NJHA is currently discussing the issue of colored wristbands for further action.
The Pennsylvania Patient Safety Authority convened a task force to develop a response to the wristband issue, and that specific event, in PA. Their work was made public in August, 2006. The task force developed a toolkit for institutions to use for increasing patient safety. The toolkit can be found at http://www.psa.state.pa.us. Once at the site, type the word “toolkit” into the search. The toolkit includes:
Pennsylvania wasn’t the only state to take action on this subject, but was the first to publish statewide guidelines. The June/July 2006 issue of Safe & Sound News of the Arizona Hospital and Healthcare Association proclaimed that by the end of the year, all hospitals in Arizona would be asked to join a statewide initiative in standardizing wristband colors. The article noted that several states are aggressively reviewing the issue, including states in the western region of the country, though it did not name the states. The article further stated that Arizona’s association had assembled a workgroup in May 2006 to study the issue and make recommendations. The group was focused on three specific conditions and the color-coding that surrounded them. At the time of the writing of the article, seven different colors were used to denote “Do Not Resuscitate” status in Arizona healthcare facilities.
The AZ workgroup’s goals were to:
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Develop a standard for colored wristbands statewide
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Agree on the definitions of the colors
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Build a workplan and a toolkit for AZ hospitals to use in adopting the new standardization plan
Other organizations have weighed in on this topic too. In an article found at www.jcipatientsafety.org, the Joint Commission International Center for Patient Safety reviewed concerns about colored plastic and rubber wristbands. The Joint Commission’s recommended strategies to prevent potential problems were:
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Consider using RFID (Radio Frequency Identification) technology for patient ID bands. This technology involves small memory chips which can hold patient data as well as special information such as blood type, allergies, and other important facts.
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Use staff education to reduce the likelihood of errors.
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Perform Root Cause Analyses on any errors that occur so that interventions can be determined and implemented.
The Institute for Safe Medication Practices’ (ISMP’s) March 9, 2006 newsletter also had an article about color-coded wristbands. The article described another band incident involving a hospitalized patient with a green band for a latex allergy. This patient was sent to an ambulatory diagnostic center for a test. Since the center did not know what the green band meant, they used latex-containing equipment during the test and the patient suffered an anaphylactic reaction.
The ISMP article went on to describe the Pennsylvania’s Patient Safety Authority (PA PSA) efforts in this area; it reprinted a table of wristband colors, and the information these wristbands were used to communicate, that the PA PSA had developed from their research. It also gave a list of recommendations to reduce band confusion which they referenced from the PA Patient Safety Authority. The recommendations were as follows:
- Limit the number of colors used.
- Use only primary and secondary colors; also don’t use shades of the same color.
- Use wristbands with short, preprinted text on the band which describes the meaning of the band, such as “fall risk.”
- Remove bands from patients who arrive with them. If patients refuse, cover the bands with a bandage or surgical tape.
- If the facility uses color-coded pediatric banding systems for pediatric resuscitation, make special efforts to reduce confusion.
The ISMP also called for a national standard for color-coding wrist bands. Given the nature of this risk, a national standard would seem to make sense, especially in areas like New Jersey, where patients are transferred from facilities across state lines, nullifying the relative safety of a state-wide color-coding system.
Conclusion
So a single question by one risk manager started a dialogue on this issue here in New Jersey. Within six to twelve months, other states were also working on their own initiatives to prevent medical errors which did, or could potentially, arise from colorful plastic or latex bands that were originally intended to help prevent error. Risk managers never work in a vacuum when they reach out with their concerns and their observations to let the rest of the team know where a new risk lies.
Princeton’s healthcare risk consultants thank all the clients who have taken the time to ask a question or point out a risk that they have noticed. You may have averted a tragedy.