Executive Summary

In December 2005, a patient safety advisory was issued from the Pennsylvania Patient Safety Reporting System. This advisory, which received national attention, described an incident that occurred in a Pennsylvania hospital where clinicians nearly failed to rescue a patient who had a cardiopulmonary arrest. 

The source of confusion was a nurse that had incorrectly placed a yellow wristband on the patient. In the hospital where the patient was admitted, a yellow wristband meant “Do Not Resuscitate”. However, at a nearby hospital where the nurse also was employed, a yellow wristband meant “Restricted Extremity”, which was what the nurse had intended to alert hospital staff about. Fortunately, another nurse recognized the mistake and the patient was resuscitated.

This incident proved that lack of consistency and uniformity in the healthcare setting can be a patient safety issue. As a result, many states have begun to work towards standardization of color-coded alert wristbands in acute care hospitals. To address this patient safety issue in Colorado, the Colorado Hospital Association (CHA) and Colorado Foundation for Medical Care (CFMC) joined forces with the Western Region Alliance for Patient Safety (WRAPS), a multi-state regional collaborative, to standardize patient alert wristbands in hospitals. In late 2006, CFMC surveyed Colorado hospitals to gather information regarding alert wristband use in these facilities. The survey was sent to all acute care and critical access hospitals in the state and 85% of hospitals responded. The survey results showed:

• Allergies:  Five different wristband colors were being used to designate an allergy. 

• DNR:  Five different wristband colors were being used to designate a DNR. 

• Fall Risk:  Six different wristband colors were being used to designate a fall risk. 

• Latex Allergy:  Six different wristband colors were being used to designate a latex allergy. 
  • Necessity of Latex Band:  The majority of hospitals were either indifferent (38%) or do not see a need for a separate latex wristband (34%). However, 20% of the hospitals did feel that a separate latex wristband is necessary.
     

• Cardiac Arrest Code Terminology:  73% of hospitals use code blue to alert hospital staff of a cardiac arrest

The choice of color to designate certain conditions is not limited to wristbands. It is the recommendation of the Quality Professionals' Group that any form of designation that is used for the five conditions be consistent with the colors of the wristbands. For example, if stickers or placards are used in lieu of a wristband to alert clinicians of a certain medical condition; then the stickers and placards should be consistent with the color that should be used for the alert wristband.       

The quality professionals that collaborated on this project recognize the possible cost that may be associated with this voluntary statewide standardization. In an effort to reduce financial burden, CHA recommends phasing in the new colors over a 12 month period following the receipt of the implementation tool kit to provide enough time for education of staff and use of out-of-date colored bands in hospital inventory. 

Colorado Alert Wristband Tool Kit 

Addendum A - Colorado Alert Wristband Tool Kit 

Staff Training PowerPoint 

Template - Staff Competency Form 

Risk Reduction Reference Card

Click here to view the fact sheet for Wristband Standardization Project