Real-life Case in a Pennsylvania Hospital
A hospital in Pennsylvania submitted a report to the Patient Safety Authority describing an event in which clinicians nearly failed to rescue a patient who had a cardiac arrest because the patient had been incorrectly designated as “DNR” (do not resuscitate). The source of the confusion was that a nurse had incorrectly placed a yellow wristband on the patient. In this hospital, the color yellow signified that the patient should not be resuscitated. In a nearby hospital, in which this nurse also worked, yellow signified “restricted extremity,” meaning that this arm is not to be used for drawing blood or obtaining intravenous (IV) access.
What You Should Know:
- About four out of five Pennsylvania facilities responding to a recent statewide survey use color-coded patient wristbands to communicate important medical information.
- Of those who use them, 98% say the color has a significant meaning.
- Color-coded wristbands are most commonly used in hospitals (87%), but they are also used in Ambulatory Surgical Facilities (67%).
- More facilities in Pennsylvania are adopting standard meanings for specific colors. While the adoption of the standard colors and meanings is not mandatory, the Authority and the Hospital and Healthsystem Association of Pennsylvania (HAP) recommends that if facilities are using color-coded wristbands that they adopt the standards set forth by the Colors of Patient Safety Task Force in northeastern Pennsylvania.
- Pennsylvania is not alone in standardizing its colors and meanings. Due to the Authority's Supplementary Patient Safety Advisory that raised awareness of the issue, several states have adopted the standards in the manual developed by the Colors of Patient Safety Task Force. Most recently, the U.S. Army adopted the standardization protocols set forth by Pennsylvania.
What You Can Do:
- Remove all wristbands that you have placed on yourself before entering a healthcare facility for medical attention if they do not give any information about your medical condition. (e.g. Lance Armstrong, “Livestrong” yellow wristbands)
- Know the purpose of a wristband placed on you or a loved one by a healthcare provider.
- Ensure any writing on the wristband is clearly understood.
- Do not be afraid to ask the healthcare provider what colors mean for each wristband in that particular hospital.
- Do not be afraid to confirm the meaning of the wristband color with any “new” nurse or healthcare provider on your case or a loved one’s while in the hospital.
- If you are transferred to another healthcare facility during care, be sure to confirm the meaning of the colored wristbands in the new facility.
For more information on the standardization of color-coded wristbands go the the Authority's website at www.patientsafetyauthority.org, go to "Browse by Topic," then click on "Event" and type in "Color-Coded Wristbands." For more copies of these consumer tips, click on "Patients and Consumers" at this same website.