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

2. 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

3. 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”.

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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

21. 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

22. 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 when you have converted to the standardized wristband colors

23. 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.

24. Direct questions to Betsy Lee, RN, MSPH Director, Indiana Patient Safety Center