A hospital in Pennsylvania submitted a report to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing an event in which clinicians nearly failed to rescue a patient who had a cardiopulmonary 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 access.
Fortunately, in this case, another clinician identified the mistake, and the patient was resuscitated. However, this "near miss" highlights a potential source of error and an opportunity to improve patient safety by re-evaluating the use of color-coded wristbands.
To assess the potential scope of the problem, PA-PSRS surveyed the patient safety officers of all Pennsylvania hospitals and ambulatory surgical facilities. The 139 survey respondents represented one-third of these healthcare facilities.
Excerpted from: Use of color-coded patient wristbands creates unnecessary risk. PA PSRS Patient Saf Advis 2005 Dec 2;(Suppl. 2). http://patientsafety.pa.gov/ADVISORIES/Pages/2005sup2_01.aspx.