Dangerous Confusion with Color-coded Wristbands - FDA Patient Safety News: Show #52, June 2006

A recent ISMP report, along with an advisory from the Pennsylvania Patient Safety Authority, points out the danger of misinterpreting the meaning of color-coded wristbands worn by patients. The confusion is often caused by certain colors having different meanings in different facilities.

In one case, a hospitalized patient was given a green wristband to show that he was allergic to latex. He was later transferred to another facility where the staff wasn't familiar with this particular color coding. They performed a test with latex-containing devices, and the patient suffered an anaphylactic reaction.

In another case, a nurse wanted to signify that a patient had a restricted extremity, so she placed a yellow wristband on him. Because she worked in several hospitals with different color coding schemes, she didn't realize that in this particular facility, yellow meant "do not resuscitate." Luckily, the mistake was caught before any damage was done.

Mistakes can also happen if you don't remove the colored wristbands that some people wear for non-medical reasons, such as to signify charitable contributions.

Here are some of the recommendations listed by ISMP and the Pennsylvania Patient Safety Authority:

• Limit the number of colors used on patient wristbands.

• Use only primary and secondary colors, and don't use shades of the same color to convey different messages.

• 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.

• Consider removing colored non-medical wristbands that patients may be wearing when they present to the facility. If that can't be done, you can cover the band with a bandage or medical tape.

• Explain the purpose of the wristband to the patient and family members, which provides another opportunity to prevent errors.

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.

Additional Information:

ISMP Medication Safety Alert . Confusion over meaning of color-coded wrist bands. March 9, 2006.
http://www.ismp.org/Newsletters/acutecare/articles/20060309_3.asp

Pennsylvania Patient Safety Authority -- Supplementary Advisory -Use of Color-Coded Patient Wristbands Creates Unnecessary Risk. December 14, 2005.

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/dec14_2(sup...


--------------------------------------------------------------------------------
FDA Patient Safety News is available at www.fda.gov/psn

Category:

Science & Technology

Tags:

• fda
• color-coded wrist bands
• patient safety health