Color-coded Wristband Standardization in Iowa “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change Background: In 2005 in Pennsylvania there was confusion regarding wristband color that resulted in a patient being labeled DNR erroneously. As a result they took the lead in standardizing colored wristbands. In 2008 the Iowa Healthcare Collaborative collected baseline data after concern was voiced about wristband variation in Iowa hospitals Although standardization of color coded wristbands in Iowa is not mandatory it is highly recommended in order to achieve statewide adoption by Iowa’s acute care hospitals. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change In the state of Iowa, it was discovered that around 73% of Iowa hospitals use colored wristbands to increase awareness of certain patient risks. However, the color and usage process varied tremendously from hospital to hospital. Results of a survey conducted by IHC are as follows: “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change What does this mean? Potential for confusion exists Opportunity to reduce potential for harm and improve patient safety The potential for confusion is obvious, significant, and avoidable. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change What did we do? Reviewed current standardization models in use Discussion and “Building the Will” for change Consensus to standardize three condition alerts Allergy Fall Risk Do Not Resuscitate Alone we can do so little; together we can do so much. ~ Helen Keller As you have heard, the initial work to standardize color-coded wristbands began in Pennsylvania. Arizona quickly followed in this patient safety endeavor to standardize color-coded wristbands in their own state. AL, AZ, CA, CO, FL, KS, MN, MO, NH, NJ, NV, NY, OH, OR, PA, UT, WA, WV and WI have adopted a standardization model. AR, IL, KY, LA, MI, NE, TX and VA are in the process of standardizing. Based on the baseline data in our state, we began discussions and there was consensus to proceed with this project. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change Arizona model Multidisciplinary work group formed through the Arizona Hospital and Healthcare Association Task: Reach consensus on color definitions Develop work plan and implementation Tool Kit Arizona’s model involved convening a workgroup. They focused on three condition alerts: Do Not Resuscitate, Allergy, and Fall Risk. The Arizona model has now been duplicated in many other states. The information that follows in this kit will guide your organization through a methodical and system wide approach for a successful implementation. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change The Tool Kit contents include: The colors for the alert designation The logic for the colors selected A work-plan for implementation Staff education including competencies The information that follows in this kit will guide your organization through: 1 & 2. The colors for the alert designation and logic for the colors selected; there were many colors to consider so we accessed other resources to make the best decision, including: Human Factors and the science of human error Other industry experts (such as ANSI – the American National Standards Institute) to determine color selection. Common sense. Where there was an already prevalence of use, we did not change. 3. Work plan for implementation; Work plans often fail because they do not consider all of the stakeholders. This work plan is comprehensive with step by step cues so stakeholders are considered and involved. 4. Staff education including competencies; The staff education includes hand outs for staff, notice reminders, sign in sheets, education brochure for staff and competencies – should you chose to use them. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change The Tool Kit contents include (cont.): Patient education brochure 6. FAQs for general distribution 7. Sample policy and procedure 8. Vendor information for easy adoption The information that follows in this kit will guide your organization through: 5. FAQs for general distribution; This is an easy to read document that provides the answers to the most common questions. 6. Sample policy and procedure; This document will need to be revised to some extent to fit your organizations’ format, however, it is an excellent resource with information that you can mostly “Cut and Paste” into your P&Ps. 7. Vendor information for easy adoption of the recommendation and This is provided because there are various hues within colors. This allows for an exact match – as close as possible. Also, it provides a sample of the text so font style and size can be as close a match as possible – regardless of vendor. 8. Patient education brochure Patients need to know what the wristbands mean because it is their life we are talking about and they can also correct any mis-information. This brochure clearly and succinctly conveys that information. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Case for Change Our safety as a state and success in this effort will depend on the participation and adoption of each Iowa hospital using alert wristbands. This effort will require a willingness to change for the greater good. Some hospitals will have a minor change while others may have a major change. We realize that change is difficult; we also realize that change made for reasons that benefit the safety of your staff, your loved ones and your communities are changes for all the right reasons. Although standardization of the color coded wristbands in Iowa is not mandatory, it is highly recommended in order to achieve statewide adoption. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Allergy Recommendation: RED for Allergy It is recommended that hospitals adopt the color RED for the ALLERGY ALERT designation with the words embossed/printed on the wristband, clasp or label, “ALLERGY.” Quick Adoption By adopting red for allergy alert, the standardization for this is easily achieved since 56% of IA hospitals reporting already use red for allergy alert. Recommendation: RED for the Allergy Alert designation Allergies “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Allergy Recommendation - RED for Allergy Alert Why Red? 56% of Iowa hospitals reporting currently use red Any other reasons? Associated with other messages such as STOP! DANGER! due to traffic lights and ambulance/police lights. Do we write the allergies on the wristband too? No because that may create new errors due to: Legibility issues Allergy list may change Patient chart should be the source for the specifics Recommendation: RED for the Allergy Alert designation Why did you select red? Red was selected due to the July 2008 survey conducted with Iowa hospitals that indicated 56% of hospitals already use the color red. It just made sense to continue with an established color that has such overwhelming use. 2. Are there any other reasons for using red? Yes there are. Our research of other industries tells us that red has an association that implies extreme concern. The American National Standards Institute (ANSI) has designated certain colors with very specific warnings. ANSI uses red to communicate “Stop!” or “Danger!”. We think that message should hold true for communicating an allergy status. When a care giver sees a red allergy alert band they are prompted to “STOP!” and double check if the patient is allergic to the medication, food, or treatment they are about to receive. 3. Do we write the allergies on the wristband too? It is our recommendation that allergies be written in the medical record according to your hospital’s policy and procedure. We suggest allergies not be written on the wristband for several reasons: Legibility make hinder the correct interpretation of the allergy listed; By writing allergies on the wristband someone may assume the list is comprehensive. However, space is limited on a wristband and some patients have in excess of 12 or more allergies. The risk is some allergies would be inadvertently omitted. Throughout a hospitalization, allergies may be discovered by other care-givers, such as dieticians, radiologists, pharmacists, etc. This information is typically added to the medical record and not always a wristband. By having one source of information t refer to, such as the medical record, staff of all disciplines will know where to add newly discovered allergies. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Fall Risk Allergies Recommendation: YELLOW for Fall Risk It is recommended that hospitals adopt the color YELLOW for the Fall Risk Alert designation with the words embossed/written on the wristband, clasp or label, “Fall Risk.” Falls account for more than 70 percent of the total injury-related health cost among people 60 years of age and older. Recommendation: YELLOW for the Fall Risk designation Why even use an alert band for Fall Risk? According to the Centers for Disease Control and Prevention (CDC), falls are an area of great concern in the aging population. According to the CDC, More than a third of adults aged 65 years or older fall each year Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes   Of those who fall, 20% to 30% suffer moderate to severe injuries that reduce mobility and independence, and increase the risk of premature death The total cost of all fall injuries for people age 65 or older in 1994 was $27.3 billion (in current dollars). By 2020, the cost of fall injuries is expected to reach $43.8 billion (in current dollars) Hospital admissions for hip fractures among people over age 65 have steadily increased, from 230,000 admissions in 1988 to 338,000 admissions in 1999. The number of hip fractures is expected to exceed 500,000 by the year 2040. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Fall Risk Allergies Recommendation - YELLOW for Fall Risk Why Yellow? Associated with “Caution” or “Slow Down” (Stop Lights and School Buses) American National Standards Institute (ANSI) All health care providers want to be alert to fall risks as they can be prevented. Recommendation: YELLOW for the Fall Risk Alert designation 1. Why did you select yellow? Our research of other industries tells us that yellow has an association that implies “Caution!”. Think of the traffic lights; proceed with caution or slow down is the message with yellow lights. The American National Standards Institute (ANSI) has designated certain colors with very specific warnings. ANSI uses yellow to communicate “Tripping or Falling hazards.” It fits well in healthcare too when associated with a Fall Risk. Care givers would want to know to be on alert and use caution with a person who has history of previous falls, dizziness or balance problems, fatigability, or confusion about their current surroundings. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Do Not Resuscitate Recommendation: PURPLE for Do Not Resuscitate It is recommended that hospitals adopt the color PURPLE for the Do Not Resuscitate designation with the words embossed/printed on the wristband, clasp or label, “DNR.” Calling CODE BLUE! Is used by the vast majority to call a code. If Iowa selected the color blue for the DNR wristband, the potential for confusion exists. “Does blue mean I code or I do not code?” Recommendation: Purple for the Do Not Resuscitate designation While there is much discussion regarding the issue of “to band or not to band”, to date a comprehensive peer-reviewed literature search has not identified better interventions. One may say, “In the good old days, we just looked at the chart and didn’t band patients at all”, however, those days consisted of a workforce base that was largely core staff employed by the hospital. Now, an increasing number of health care providers are not hospital based staff, so it is imperative that current processes take this into consideration. Wristbands are used in many Iowa hospitals to communicate an alert. Registry staff, travelers, non-clinical staff, nursing students, and medical healthcare providers, etc would most likely be unaware of where to look in the medical record. By having a wristband on, a quick warning is communicated so anyone could know about this alert. Additionally, it is also a means to communicate to the family and significant others that we are clear about their end of life wishes. By not having a band on, errors of omission could potentially be created. When seconds count, as in a code situation, we believe having an alert wristband on the patient will serve as a great tool. Similar to a second identifier, it will serve as a ready communication in a crisis situation, an evacuation situation, or in a transit situation. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Do Not Resuscitate Recommendation - PURPLE for Do Not Resuscitate Why not blue? Should not be the same color that is used for calling a code Registry, turnover, travelers, etc. Why not green? Color-blind “Go ahead” confusion If we adopt purple, do we still need to look in the chart? Yes! Code designation can and does change during a patients stay Recommendation: Purple for the Do Not Resuscitate designation 1. Why not use Blue? The work group considered the work in Pennsylvania, where blue is used to standardize DNR, and Arizona and the 23 additional states that have subsequently adopted purple to standardize DNR, and the rationale behind their decisions. It also took into consideration that the vast majority utilize a call of “code blue” to summon the resuscitation team. By also having the DNR wristband as “no code,” there was potential for confusion. “Does blue mean we code or do not code?” To avoid creating any second-guessing in this situation, the decision was made to adopt the same guideline as in the majority of states — purple to designate DNR. In June 2008 Pennsylvania decided to designate purple for DNR in order to standardized with the other states. 2.. Why not use Green? We considered this color as well, however, due to color blindness concerns it was decided to avoid it altogether. Also, in other industries, the color green often has a “Go Ahead” connotation, such as traffic lights. We again want to avoid any possibility of sending “mixed messages” in a critical moment. 3. If we adopt the purple DNR wristband do we still need to look in the chart? Yes. Some hospitals do not use wristbands for DNRs because they want the chart to be reviewed first for the most current code designation. However, that practice should be the practice in all cases - whether a wristband is being used or not. Code status can change throughout a hospitalization. It is important to know the current status so the patient’s and families wishes can be honored. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Work Plan “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Work Plan Documents A suggested Work Plan for Facility Preparation, Staff Education, and Patient Education that includes: Organizational Approval Supplies Assessment and Purchase Hospital Specific Documentation Staff and Patient Education Materials and Training Following the Work Plan is a Task Chart for each plan that provides cues for methodical and successful implementation. “Patient safety is sound clinical practice”

“Patient safety is sound clinical practice” Color-coded Wristband Standardization in Iowa Sample Work Plan Document This document has been designed to assist you in considering the stakeholders and the depth of a system-wide implementation. There may be more steps than these – or less, depending on your organizations infrastructure. Use this as a tool and add to it as you need. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Sample Task Chart This document has been designed to assist you in very specific tasks that need to be considered when launching a change like this. There may be more steps than these – or less, depending on your organizations infrastructure. Use this as a tool and add to it as you need. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Policies & Procedures A template Policies & Procedures has been provided. Make modifications to it so it fits your organization’s process and culture. Includes a “Patient Refusal to Participate in the Wristband Process” process. Always remember that when surveyors or regulatory entities visit your organization, they will survey your performance according to the policies you have implemented. That being said, be sure that your final policy and procedure for the wristbands is “do-able.” This template has been provided for your consideration – adopt all of it or none of it…but do review your current policy and update it to reflect your current changes. “Patient safety is sound clinical practice”

“Patient safety is sound clinical practice” Color-coded Wristband Standardization in Iowa Excerpt from Refusal Form The patient refuses to: □ Wear color-coded alert wristbands. • I have been told why I should wear a color-coded wristband. • I understand why I should wear a color-coded wristband. • I will not wear a color-coded wristband. □ Remove “social cause” colored wristbands (like “Live Strong” and others). • I have been told why I should remove my “social cause” wristband. • I understand why I should remove my “social cause” wristband. • I will not remove my “social cause” wristband. Reason given (if any): ____________________________________________________ _______________________________________________________________________ _____________ ________________________________________________ Date / Time Signature/Relationship Date / Time Witness Signature/Job Title If a patient refuses to wear a band, how do you document that? This form facilitates that process of documentation. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education Tools for Staff Education: Poster announcing the training meeting dates/times Staff Sign-In Sheet Staff competency check list Tri-fold Staff education brochure about this initiative FAQs hand out for staff Tri-fold Patient education brochure about color coded wristbands PowerPoint presentation These tools are included in the tool kit. They are designed to help you. Use them as you see fit. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education Tri-fold Staff education brochure that includes: How this all got started…The Pennsylvania story Why we need to do this in Iowa The National picture What the colors are for Allergy, Fall Risk and DNR Script for any staff person talking to a patient or family about the wristbands “Quick Reference Card” cut out that lists 7 other risk reduction strategies  This brochure was designed to be reprinted for all staff training. This brochure has been produced in black and white. A color version will be available at the FHA website, patient safety page “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education Color Coded “Alert” Wristbands / Risk Reduction Strategies A Quick Reference Card ==================================== Use wristbands with the alert message pre-printed (such as “DNR”) Remove any “social cause” colored wristbands (such as “Live Strong”) Remove wristbands that have been applied from another facility. The following information takes each risk reduction strategy and provides further detail and / or explanation of that strategy. 1. Use wristbands that are pre-printed with text that tells what the band means. This can reinforce the color coding system for new clinicians, help caregivers interpret the meaning of the band in dim light, and also help those who may be color blind. Eliminates the chance of confusing colors with alert messages 2. Remove any “social cause” (such as Live Strong, Cancer, etc.) colored wristbands. Be sure this is addressed in your hospital policy and during patient education. Goal is for the patient and family to understand that the removal of wristbands is solely done to enhance patient safety processes. If that can't be done, you can cover the band with a bandage or medical tape, but removal altogether is best 3.Remove wristbands that have been applied from another facility. This should be done during the entrance to facility process and/or admission Be sure this is addressed in your hospital policy “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education Color Coded “Alert” Wristbands / Risk Reduction Strategies A Quick Reference Card ==================================== 4. Initiate banding upon admission, changes in condition, or when information is received during hospital stay. 5. Educate patients and family members regarding the wristbands 6. Coordinate chart/ white board/care plan/door signage information/stickers with same color coding 7. Educate staff to verify patient color coded “alert” arm bands upon assessment, hand- off of care and facility transfer communication. The following information takes each risk reduction strategy and provides further detail and / or explanation of that strategy. Initiate banding upon admission, changes in condition, or information received during hospital stay. 5 .Educate patients and family members regarding purpose and meaning of the wristbands. Including the family in this is a safe guard for you and the patient Remind them that color coding provides another opportunity to prevent errors. Use the Patient / Family Education brochure located in the tool kit 6. Coordinate chart/ white board/care plan/door signage information/stickers with same color coding. For allergies, fall prevention and DNR status. Educate staff to verify patient color coded “alert” wristbands upon assessment, hand- off of care and facility transfer communication. Remember, the wristband is a tool to communicate an alert status. Other points to make include Educate staff to utilize the patient, medical record information (physician order for DNR) as additional resource for verification process for allergies, fall risk, and advance directives. When possible, limit the use of colored arm bands. Such as, for other categories of care (i.e. latex, MRSA, tape) If your facility uses pediatric wristbands that correspond to the Broselow color coding system for pediatric resuscitation, take steps to reduce any confusion between these Broselow colors and the colors on the wristbands used elsewhere in the facility. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education Why have a Script for Staff? We know how we say something is as important as what we say. This provides a script sheet so staff can work on the “how” as well as the “what.” Serves as an aid to help staff be comfortable when discussing the topic of a DNR wristband. Promotes patient/family involvement and reminds the patient/family to alert staff is information is not correct. By following a script, patients and families receive consistent message – which helps with retention of the information. Patient Education brochure also available for staff to hand out. Teaching Patients - The Patient Education brochure is a companion document to the staff brochure. We know that how we say something is just as important as what we say. Patients and their loved ones are scared, vulnerable and unfamiliar with hospital ways. We need to communicate to them in a respectful and simple way without being condescending. The following text was written to serve as a “script” for staff so all could be delivering the same information to patients and families. By having a consistent message, we reinforce the information – this helps patients and families retain the information. Another benefit of having a consistent message is patients and families experience a sense of confidence in the health care system since we are all echoing each other. The text box below is taken directly from the staff brochure. This is the time to mention to staff there is a patient / family brochure that can be handed out (if your unit intends on doing that). Tell staff you will hand out the brochure to them so they can see what the patients will have when you are done presenting the material. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education SCRIPT for any staff person talking to a patient or family What is a Color Coded “Alert” Wristband? Color coded alert wristbands are used in hospitals to quickly communicate a certain health care status, condition, or an “alert” that a patient may have. This is done so every staff member can provide the best care possible. What do the colors mean? There are three different color coded “alert” wristbands that we are going to discuss because they are the most commonly ones used. ~ continued on next slide~ “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education SCRIPT for any staff person talking to a patient or family RED means ALLERGY ALERT If a patient has an allergy to anything - food, medicine, dust, grass, pet hair, ANYTHING- tell us. It may not seem important to you but it could be very important in the care the patient receives. YELLOW means FALL RISK We want to prevent falls at all times. Nurses assess patients all the time to determine if they need extra attention in order to prevent a fall. Sometimes, a person may become weakened during their illness or because they just had a surgery. When a patient has this color coded alert wristband, the nurse is indicating this person needs to be closely monitored because they could fall. ~ continued on next slide~ “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Staff Education SCRIPT for any staff person talking to a patient or family PURPLE means “DNR” Or Do Not Resuscitate Some patients have expressed an end-of-life wish and we want to honor that. “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa “Patient safety is sound clinical practice”

Color-coded Wristband Standardization in Iowa Resources Questions? Contact Gail Meyer at: (515) 283-9322 or meyerg@ihconline.org You may access the online information at www.ihconline.org. Click on the “Tool Kit” header at the top of the page. Select Wristband Tool Kit. Find the file that contains the document you need. “Patient safety is sound clinical practice”