Pennsylvania Patient Safety Authority issued an advisory about potential risks of misinterpreting wristbands in 2005. This advisory led to a pilot project among 11 Pennsylvania hospitals to create a standardized color coding system. The Hospital and Healthsystem Association of Pennsylvania (HAP) has encouraged all hospitals in the state to adopt the color coded patient wristband system also known as “Banding Together for Patient Safety.” Near misses and medical errors as a result of wrong color coded bracelets have been reported by various hospitals over the years to the Patient Safety Authority (PSA). Pennsylvania Patient Safety Reporting System (PA-PSRS) acknowledges receiving a report in which a clinician nearly failed to resuscitate a patient who was incorrectly designated as DNR (do not resuscitate). A nurse had placed a yellow wristband on a patient believing that it meant “restricted extremity;” however, in the given hospital yellow signified DNR.
PS-PSRS surveyed reports that 78% of facilities use color coded patient wristbands. Lack of standardization presents problems when patients are transferred to a different facility; it also occurs when healthcare providers work in or move across facilities and possibly make assumptions about the designation of a given color. Medical information commonly communicated with wristbands includes: allergies, fall risk, restricted extremity, DNR status, and blood type/blood bank ID. Clearly, the potential for serious medical errors exists.
Crozer-Keystone Health System has re-evaluated the various color coded bracelets used throughout the various hospitals and has elected to change and adopt new color coded wristbands. Target date for new color coded wristbands is July 7, 2009. This initiative will standardize colors across the system and ensure consistency with other Pennsylvania Hospitals. Not all colors will be utilized in every hospital, but colors will be standardized.
A new administrative policy was developed to address this. It provides a listing of all color bracelets, purpose for given bracelet, and which sites the given bracelet will be utilized.
Please note that the color purple will no longer be utilized…in some facilities across the country it means DNR so CKHS will not be using this color moving past July 7th. The following colors will be implemented at CKHS facilities:
White - Inpatient/Outpatients
Orange- ED patients
Green w/White Label ED Fast Track - Taylor only
Green - Latex Allergy
Red - Medication Allergy
Yellow - Falls
Neon Pink - Contact Isolation—CCMC, TH, SH
Neon Green - Airborne Isolation—CCMC, TH, SH
Neon Orange - Droplet Isolation—CCMC, TH, SH
Pink - Restricted Limb—DCMH
Blue - Labor & Delivery Support Person-DCMH, CCMC
Patients will be asked to remove any “Charity” colored wristbands so there is no misinterpretation by care givers.
For further information call Risk Management and/or Patient Safety Officer.