Pump Color-Code Issue

The CADD-Solis Ambulatory Infusion Pump is a portable smart infusion pump that allows hospitals to customize various pain management protocols for a variety of therapies, patient types, and delivery routes, including IV patient controlled analgesia (PCA), epidural PCA, subcutaneous PCA, intrathecal opioid infusions, and peripheral nerve blocks. Clinicians can recognize which protocol is being used because the pump uses color-coding for the graphic display screens (see Figures 1 and 2). However, the color-codes are not standardized. They are set by the individual hospital during customization, not the manufacturer, Smiths Medical. Unfortunately, this could lead to a situation where a nurse “floating” from one CADD-Solis hospital might confuse a color-code when working at a different hospital that uses these pumps. We have encountered similar situations with the use of color-coded patient identification wristbands that were not standardized between hospitals.

In our March 9, 2006 newsletter, we mentioned an episode 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. More recently, hospitals around the country have undertaken efforts to standardize wristband colors. We’ve contacted Smiths Medical, and they have agreed to work with us to standardize the color-coding system used for their pumps so that confusion among facilities can be avoided.