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Confusion over meaning of color-coded wristbands

From the March 9, 2006 issue
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A hospitalized patient with a prior anaphylactic reaction to latex was given a green bracelet

which, at this hospital, signaled a latex allergy. During his stay, he was transported to an ambulatory diagnostic center for a test. Staff at the center were not aware that green bracelets meant a latex allergy and performed the testing with latex-containing vials/syringes. The patient experienced an anaphylactic reaction and required medical treatment to correct the situation.

20060309_RingsAn interesting survey of Pennsylvania (PA) hospitals, surgery centers, and birthing centers was conducted by the PA Patient Safety Authority (PSA) and published in a recent Supplementary Advisory.1 The survey found that four out of five facilities use color-coded patient wristbands to signal important medical information. However, the potential for confusion is great, and the Advisory included another event reported to the PA Patient Safety Reporting System in which a patient had been incorrectly identified as DNR (do not resuscitate) during an arrest. A nurse had mistakenly placed a yellow wristband on the patient which, in this hospital, was used to designate DNR status. The nurse worked at another hospital in which yellow wristbands were used to identify a "restricted extremity" that should not be used for drawing lab studies or IV access. Luckily the mistake was quickly realized and the patient was rescued.

The survey identified wide variation among PA facilities regarding the colors used to communicate information via wristbands (see Table). The survey also found that only one-third of the responding facilities require patients to remove the popular colored, non-medical wristbands used to show support for charitable endeavors. According to the Advisory, wristbands may also be omitted when they should be put on, removed for a procedure and not replaced, or removed or covered up by clinicians or patients.

It seems clear that a national standard is needed to assign specific colors used with wristbands if they are used to communicate various types of clinical information. Until that time, see the left-hand column for recommendations that the PSA offered to reduce confusion.

Reference appears in left-hand column.

Color-Coded Chart

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