HARRISBURG: Hospitals in northeastern and central Pennsylvania are working together to develop standards for the use of color-coded patient wristbands in their facilities. Wristband colors are often used to convey clinical information to nurses, physicians and other healthcare workers, but potential safety issues were raised when a patient nearly died in a Pennsylvania hospital due to confusion about the meaning of a colored wristband that had been put on the patient’s arm.
Although the mistake was caught in time, the incident raised the possibility of real patient harm, even death, if a wrong wristband is used. Following the incident, the Patient Safety Authority issued a special Patient Safety Advisory in December 2005 to alert the healthcare industry to this potential problem and to suggest steps facilities could take to reduce the risk of patient harm.
A group of facilities formed the “Color of Safety Task Force” to develop detailed protocols, including a policy manual and training resources, to reduce the risk of medical error when using color-coded wristbands. The Task Force has made the manual and related materials available to other facilities through the Patient Safety Authority’s website. All facilities can adopt or adapt the manual for their own use.
Bonnie Haluska, associate vice president of the Allied Services Rehabilitation Hospital in Scranton and chair of the Task Force, explains the role of the regional initiative.
“The goal of the consortium was to standardize policies and procedures and to implement strategies that reduce the possibility of miscommunication and/or error. All hospitals represented in our Task Force have enthusiastically expressed their support in participating in this worthwhile endeavor. Patient safety is paramount at all our facilities.”
Task Force members attended a recent Board of Directors meeting held by the Patient Safety Authority to update board members on its progress. Alan B.K. Rabinowitz, administrator of the Patient Safety Authority, said board members were impressed with the presentation made by the Task Force.
“The Authority welcomes the grassroots effort made by these hospitals to improve patient safety in their facilities,” said Rabinowitz. “These hospitals recognized the important ‘lesson learned’ as a result of this incident, and they worked together in a collaborative fashion to establish a protocol that can also help other organizations improve patient safety in their own facilities.”
Rabinowitz noted that the Authority’s goal in issuing Advisories is to encourage facilities to learn from events and implement appropriate changes to prevent a similar event from happening in their own institutions. “This group of hospitals rose to the challenge,” Rabinowitz said, “and they successfully engaged healthcare workers, patients and members of the community in this patient safety campaign.”
The Pennsylvania healthcare organizations involved in the Color of Safety Task Force include:
- Allied Services Rehabilitation Hospital (Scranton)
- Community Medical Center (Scranton)
- Holy Spirit Health System (Camp Hill)
- John Heinz Institute (Wilkes-Barre)
- Marian Community Hospital (Carbondale)
- Mercy Hospital (Scranton)
- Mid-Valley Hospital (Peckville)
- Moses Taylor Hospital (Scranton)
- Pocono Medical Center (East Stroudsburg)
- Tyler Memorial Hospital (Tuckhannock)
- Wayne Memorial Hospital (Honesdale)
The Authority has issued a new Patient Safety Advisory providing information on the Color of Safety Task Force and the accompanying Colored Wristband Toolkit. The toolkit includes valuable materials to help providers and facility managers implement changes in their own institutions: 1) an implementation and policy manual developed by the Task Force; 2) a brochure for provider and patient education; 3) presentations that can be used for educating staff and community members; 4) relevant Advisories from PA-PSRS; and 5) a related video from the Food and Drug Administration’s Patient Safety News highlighting the issue of wristband use.
For the complete Patient Safety Authority Supplementary Advisory entitled “Update on Use of Color-Coded Patient Wristbands” go to http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/aug9_3(suppl1)/Documents/aug9_3(suppl1).pdf.
For the Colored Wristband Toolkit, go to http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/wristbands/Pages/home.aspx.
BACKGROUND
The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act as amended, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all Pennsylvania-licensed hospitals, birthing centers, ambulatory surgical facilities and certain abortion facilities are required to report what the Act defines as “serious events” and “incidents” to the Authority. More than 445 healthcare facilities are subject to Act 13 reporting requirements.
Facilities submit reports of serious events and incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web-based system that was developed for the Authority under a contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.
More than 350,000 reports have been submitted through PA-PSRS since the program was initiated in June 2004. Ninety-six percent of these reports are Incidents or “near-misses.” Based on those reports, the Authority issues quarterly and supplementary Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm.
For more information on the Patient Safety Authority, PA-PSRS or previous Patient Safety Advisories, visit the Authority’s website at www.patientsafetyauthority.org.
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