Will color-tinted IV tubing help?
From the July 30, 2009 issue
Color has often been used effectively to capture attention or differentiate items, but its use in healthcare as a patient safety strategy has frequently fallen short of achieving its intended results. Overuse of color-coding, overreliance on color to identify items rather than enhance or differentiate them, lack of standard colors to ensure meaning, use of too many colors to be distinguishable and memorable, and assigning a single color to multiple items that are different but within the same general category, have exhausted many of the potentially positive attributes of using color to improve patient safety.
For example, in our March 9, 2006 newsletter (www.ismp.org/Newsletters/acutecare/articles/20060309_3.asp), we mentioned that armband colors used to communicate patient status may differ among hospitals. Despite recent efforts to standardize armband colors within states, staff who have changed jobs or work in multiple hospitals have misinterpreted the meaning of the color schemes used for patient armbands at different hospitals. In our December 18, 2008 newsletter (www.ismp.org/Newsletters/acutecare/articles/20081218.asp), we wrote about the potential for serious mix-ups among various drugs within a class when using syringes that are color-coded according to ASTM International (originally known as the American Society for Testing and Materials) established classes of anesthesia drugs. Color-coding the label and package of whole classes of medications has also led to frequent mix-ups among different ophthalmics or strengths of ophthalmics within the same class. Mix-ups have also occurred because there is too little difference between the colors in the color scheme. In our May 7, 2009 newsletter (www.ismp.org/sc?k=ac20090507), we brought attention to ambulatory infusion pumps (Smiths Medical) with color-coded screens for which the user decides which colors are associated with which types of infusions (e.g., IV PCA, epidural PCA, subcutaneous PCA)—another set-up for mistakes because the meaning of the color is inconsistent. In our June 4, 2009 newsletter (www.ismp.org/sc?k=ac20090604), we described an oral liquid medication that was administered IV because the purple connector for enteral use at this hospital was the same shade of purple used with Bard PowerPICC IV connectors.
The latest example of the use of color to improve safety involves a new company that will be accepting orders for color-tinted IV tubing within the next few weeks. The Safety Line System (www.safetylinesystem.com) of tinted intravenous lines offers gravity drip IV administration sets in a variety of colors—orange, red, pink, purple, violet, green, yellow, and blue—to be used in combination with corresponding wrap-around, colored labels, which are provided with each tubing set. It is unclear how these administration sets could be used with infusion pumps, although the manufacturer told us that the tubing could be used for pumps that allow the use of non-dedicated administration sets (e.g., certain syringe pumps).
The Safety Line System company correctly points out that tubing misconnections are a risk that increases as the number of parenteral, epidural, and enteral lines attached to the patient increases. The company believes healthcare providers can distinguish the lines more easily and trace the colored IV tubing from the patient to the source bag with a similarly colored label. On the plus side, the colored tubing may very well help in tracing an IV line from bag to point of catheter insertion. However, careful evaluation of known problems associated with color-coding or color-differentiation of healthcare products should occur before the product is considered for use.
Color memory. Human factors studies have established that we have poor memory recall of specific colors,1-4 particularly shades of a similar color such as purple, blue, and violet. We cannot discern subtle distinctions in color unless they are adjacent to each other. Without efforts to boost memory, we also tend to remember the meaning of only a small set of colors. Thus, color-coding that employs an extensive line of colors, such as ophthalmics, may not be memorable or distinguishable.
Color mix-ups. In the case of color-tinted IV tubing, yellow color-tinted IV tubing may look too similar to epidural tubing, which has a yellow stripe down its length. Clear tubing that is infusing a solution with multivitamins or certain antibiotics or antifungals may look similar to the yellow-tinted tubing. Red and blue chemotherapy products infusing through clear lines may resemble color-tinted tubing that has been assigned to a different drug or class of drugs. Hospital-assigned meanings of various tubing colors may differ from some longstanding color schemes such as the color-code assigned to certain drugs used with anesthesia-applied labels. The color tint of the tubing may look different than expected if running an opaque white solution or a solution with color (although the company told us that the labeling will recommend use with clear solutions only). A red drug like DOXOrubicin may give yellow tubing an orange tint. Purple or violet tubing may lead to an accidental association with enteral equipment or PowerPICC vascular tubing. Additionally, a nurse could attach different color tubing to an IV bag dispensed from the pharmacy with a color-coded label, potentially causing confusion, tubing misconnections, or administration of a drug through the wrong access port.
Color misperception. Certain performance shaping factors such as a dark patient’s room at night or staff color blindness may lead to misperceptions of the colors assigned to healthcare products.
Lack of color standardization. For the most part, healthcare has not standardized the meaning of certain colors. This allowed one company to produce purple enteral equipment and another company to produce purple PICC lines. Variations can also occur within health systems—two units using different color pump screens for the same drug—and among health systems—two hospitals using different color-tinted IV tubing for the same drug. Both situations can lead to harmful mix-ups by floating, reassigned, or new staff. Substituting clear or a different color of tubing for the intended color during a temporary shortage can also lead to errors. In short, we cannot rely on color as a safety feature until we all agree on its meaning and appropriate utilization.
Reliance on color-coding as a safety feature can instill a false sense of security in a high-risk industry like healthcare. Without careful consideration of the risk factors, the use of color has led to unintended and sometimes harmful consequences. There is wide agreement that color enhancement and differentiation is more effective than color-coding.1-4 Thus, color should never be used as the primary means of identifying items; it should only be used to help locate and differentiate items. See the definitions of color-coding and color enhancement/ differentiation in the sidebar at the bottom left. Furthermore, the meaning of certain colors should be standardized across the healthcare setting and defined to represent a distinct single entity (not a whole class of drugs, for example). Overuse or misuse of color as a safety feature in healthcare can only reduce its effectiveness, so use it sparingly and carefully. Please see our November 13, 2003, newsletter (www.ismp.org/Newsletters/acutecare/articles/20031113.asp) for more information about the problems with using color as a safety measure in healthcare.