Indiana Hospital Association Color-coded Wristband Alert Standard The Color of Safety Indiana Hospital Association Color-coded Wristband Alert Standard

Impetus for Standardization Pennsylvania – wrong color Do Not Resuscitate band applied by nurse who works in two different hospitals with two different protocols Multiple states initiated standardization efforts over past several years. American Hospital Association issued advisory on September 4, 2008 recommending standardization to 3 colors – Red for allergies Yellow for falls risk Purple for DNR

Background December 2005 Pennsylvania Patient Safety Authority (PSA) released an advisory about a recent “near-miss” report involving confusion caused by color coded patient wristbands Clinicians almost failed to resuscitate a patient in cardiopulmonary arrest because that patient was incorrectly designated as Do Not Resuscitate (DNR) Source: Pennsylvania Patient Safety Reporting System (PA-PSRS). Color-coded patient wristbands create unnecessary risk. Supplementary Advisory. 14 Dec 2005;2(S2):1-4. The problem was caused by a nurse who placed a yellow wristband on the patient. In that hospital, the color yellow signified DNR. However, the nurse has worked in several hospitals where yellow wristbands have different meanings. In a nearby hospital the color yellow signified “restricted extremity”.

Background (cont.) Lack of consistency in the meaning of color coded patient wristbands problematic: Patients being transferred among hospitals Patients under the care of clinicians who work in multiple hospitals Pennsylvania case Mistake quickly realized and patient was rescued

National Survey American Society for Healthcare Risk Management (ASHRM): Leader in wristband color coding national initiative Nation-wide survey in 2007 50 states 4 others (e.g. D.C. & Military Health Services) 100% response rate Source: American Society for Healthcare Risk Management (ASHRM). Color Coding Wristbands: A Nationwide Practice Survey. Survey assessed color coded wristband usage, models and band colors

National Survey (cont.) Survey results: 60% of the survey population: Actively discussing Developed/developing a model, or Have adopted existing model Color coded wristbands are used most frequently for DNR, Allergy and Fall Risk categories

National Survey (cont.) Allergy National color acceptance of RED Fall Risk National color acceptance of YELLOW DNR Most variation (e.g. PURPLE & BLUE) Restricted Limbs Moderate color acceptance of PINK Latex Allergy Moderate color acceptance of GREEN ASHRM will take a position on the issue using the information from the survey.

Indiana Survey 2/08 93 hospitals responded Surveys sent out to Patient Safety Officers and Chief Nursing Executives 93 hospitals responded 73.6% of hospitals use color coded patient wristbands 72.9% of hospitals do not emboss or imprint the risk/condition on the band 6.6% Not currently, but considering use Example: Allergies are written with a permanent marker and the allergy band is marked.

Indiana Survey Summary Significant variation in Indiana hospitals regarding use of color coded patient wristbands: DNR and Fall Risk represented 9 ways 39% use red for Allergy Latex Allergy represented 10 ways 69% use no bands for Restricted Extremity 74% use white bands for Patient ID

Indiana Hospital Association Action Council on Quality and Patient Safety Discussed issues related to lack of national or state standard on the use of wristband colors at February 2008 meeting Council recommended delaying action until national recommendations were available Sent a recommendation to the IHA Board of Directors for wristband standardization in Indiana in September 2008 after AHA advisory released IHA Board of Directors Approved a resolution and Council recommendations in November 2008

Assessment of Current Environment Patient safety is a key focus in all Indiana health care facilities Significant variation exists in hospitals Confusion with social cause wristbands Health care staffing and patient movement Physicians and staff working at multiple organizations Agency nurses and other staff Multiple state system hospitals and hospitals near state borders Patient transfers Human factors research supports standardization

Standardization by State 2/09 KEY Implemented at least 2-5 standard colors Standardizing in 2009 No standardization or plan of standardization

Summary Safety is a key priority for Indiana health care organizations Near misses have been reported in other states Many Indiana systems/regions are interested in standardizing communication about patient information and risks Not all Indiana hospitals use color as a safety alert For hospitals that do use color as a safety alert, there is significant variation Many of our neighboring states have already adopted or are considering wristband color standards

Indiana Hospital Association Recommendation The Board of Directors of the Indiana Hospital Association recommends that all hospitals evaluate methods to effectively communicate patient information and risks. The use of wristband colors for patient alerts is not required, but If an organization elects to use color-coded alerts to communicate patient information or risks, the Association encourages Indiana hospitals to use the following colors: RED ALLERGY GREEN LATEX ALLERGY YELLOW FALL RISK PURPLE DO NOT RESUSCITATE WHITE PATIENT IDENTIFICATION PINK LIMB ALERT/RESTRICTED EXTREMITY

Red - Allergy Recommendation: It is recommended that if a hospital chooses to use a color to designate patient allergies, that it adopt the color of RED for the Allergy designation with the word “Allergy” embossed/printed on the alert. Hospitals should develop a consistent process for indicating specific allergy (i.e. – note all allergies in the medical record). Q. Do we write the allergies on the alert too? A. It is recommended that allergies be written in the medical record according to your hospital’s policy and procedure and should not be written on the alert for several reasons: Legibility may hinder the correct interpretation of the allergy listed. By writing allergies on the alert someone may assume the list is comprehensive. However, space is limited on an alert and some patients have multiple allergies. The risk is that some allergies would be inadvertently omitted—leading to confusion or missing an allergy. By having one source of information to refer to, such as the medical record, staff of all disciplines will know where to find a complete list of allergies. Throughout a hospitalization, allergies may be discovered by clinicians such as dieticians, radiologists, pharmacists, etc. This information is typically added to the medical record and not always to the alert. By having one source of information to refer to, such as the medical record, staff of all disciplines will know where to add newly discovered allergies.

Green – Latex Allergy Recommendation: It is recommended that if a hospital chooses to use a color to designate latex as a specific allergy, that it adopt the color of GREEN for the Latex Allergy designation with the letters “Latex Allergy” embossed/printed on the alert. Q. Why should we use wristbands for latex allergy alerts? Many products used in hospitals are made of latex and can cause certain patients to have a severe allergic reaction. When a patient is wearing this wristband it alerts hospital staff that they have allergies to products containing latex and non-latex supplies should be used. Can our hospital use a red alert band to designate all types of allergies? Yes. It is not mandatory for a hospital to adopt any color wristband to designate patient alerts. Some hospitals may find a benefit in adopting a separate color for latex allergies, in which case, we recommend green. Otherwise, a red band is sufficient with the specific type of allergy noted in the medical record.

Yellow - Fall Risk Recommendation: It is recommended that if a hospital chooses to use a color to designate falls risk that it adopt the color of YELLOW for the Fall Risk designation with the words “Fall Risk” embossed/written on the alert. Q. Why did you select Yellow? A. Research of other industries tells us that yellow has an association that implies “Caution!” Think of traffic lights: yellow lights mean proceed with caution or stop altogether. The American National Standards Institute (ANSI) has designated certain colors with very specific warnings. ANSI uses yellow to communicate “Tripping or Falling hazards.” This fits well in healthcare when associated with a Fall Risk. Caregivers 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. Q. Why even use an alert for Fall Risk? A. According to the Centers for Disease Control and Prevention (CDC), falls are an area of great concern in the aging population. More than a third of adults age 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.

Purple - DNR Recommendation: It is recommended that if a hospital chooses to use a color to designate a patient’s preferences for end-of-life care associated with DNR status that it adopt the color of PURPLE for the Do Not Resuscitate designation with the letters “DNR” embossed/printed on the alert. Q. Should we use wristbands for DNR designation? While there is much discussion regarding the issue of “to band or not to band,” a literature review to date has not conclusively identified a better intervention in an emergency situation. 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 work- force that was largely employed by the hospital. Today, an increasing number of healthcare providers working in hospitals are not hospital-based staff or work for more than one facility. Travel staff may not be as familiar with how to access information (as in the use of computerized medical records) or may not be familiar with where to find information in the medical record. When seconds count, as in a code situation, having a wristband on the patient is one way to improve communication and reduce the risk of an error. Q. Why not use Blue? A. At first, blue was considered a great color choice. However, many hospitals utilize “Code Blue” to summon the resuscitation team. By also having blue as the DNR alert color, there is the potential to create confusion. “Does blue mean we code or do not code?” To avoid creating any second guesses in this critical moment, we opted to not use blue.

Pink – Limb Alert/Restricted Extremity Recommendation: It is recommended that if a hospital chooses to use a color to designate restricted extremity that it adopt the color of PINK for the Limb Alert designation with the letters “Limb Alert” embossed/printed on the alert. Q. Why should we use wristbands for limb alerts? A. Some patients have conditions that restrict the use of a certain arm or leg. Patients with this condition wear a pink band on the affected extremity to alert staff to avoid using this limb for blood draws, IV insertions, and other medical procedures.

IHA Council on Quality & Patient Safety Recommendation Hospitals that do not use color alerts should consider whether the standardized colored wrist bands are the best solution for their hospital Hospitals using color alerts (wristbands, stickers, etc.) are encouraged to use the Indiana standard to improve communication RED ALLERGY GREEN LATEX ALLERGY YELLOW FALL RISK PURPLE DO NOT RESUSCITATE WHITE PATIENT IDENTIFICATION PINK LIMB ALERT/RESTRICTED EXTREMITY Other color alerts based on hospital choice Limit additional alerts to only those needed Use only primary and secondary colors; avoid shades of colors Select wristbands with preprinted text Do not write allergies or other patient specific information on wristbands except for patient identification Engage the patient and their family in a dialog to identify risk Request patients remove colored social cause wristbands

Toolbox Contents Distribution Communication   Contents Voluntary Indiana color-coded alert standards manual Sample policy Sample staff education brochure Sample staff competency check list Sample project plan Sample patient education brochure Distribution Electronic notice sent to each hospital Nursing Quality Communication Organizational newsletters & Website

Timeline & Tracking Goal: 100% voluntary use of Indiana standard colors by December 31, 2009 for hospitals using color-coded wristband alerts Notify IHA by contacting Mikell Brown at mbrown@ihaconnect.org when you have converted to the standardized wristband colors

Acknowledgements In the spirit of sharing best practices for improvement, many sources contributed to the background and materials for this implementation toolkit. The Indiana Hospital Association and the Indiana Patient Safety Center gratefully acknowledge the following organizations and individuals: The Pennsylvania Color of Safety Task Force, which developed the initial policy regarding wristband color standardization. The Arizona Hospital and Healthcare Association for their work to develop the initial implementation toolkit. The Wisconsin Hospital Association (WHA), whose adaptation of the toolkit was modified for use in Indiana. Particular thanks go to Dana Richardson at WHA for granting permission for the use of their work. Special thanks to Jessica Langlois, Ashley Canon, Madilyn Moran, and Sarah Goranovich, BSN students at the Purdue University Calumet School of Nursing, for providing materials which were also adapted for this toolkit.  

Direct questions to Betsy Lee, RN, MSPH Director, Indiana Patient Safety Center blee@ihaconnect.org 317-423-7795