PATIENT SAFETY: A crystal-clear call to standardize color-coded wristbands
Karen E. Cizek MSN, RN
Nicolette Estrada PhD, MAOM, RN, FNP
Jan Allen MSN, RN, CIC, CPHQ
Teresa Elsholz MSN, RN

$3.95
Nursing2014
May 2010 
Volume 40  Number 5
Pages 57 - 59
 
  PDF Version Available!

ABSTRACT
YOUR PATIENT Mary Jones, 82, is transferred from a long-term-care (LTC) facility to a medical unit for treatment of pneumonia. She has a history of a stroke with left-sided hemiparesis, and she had a left mastectomy 15 years ago. She's allergic to penicillin and latex. Her admitting orders include a do-not-resuscitate (DNR) order.On your initial assessment, you note that Mrs. Jones is wearing wristbands in five different colors, plus a black-and-white ID wristband. When you begin to remove all the wristbands, Mrs. Jones objects, saying, "They told me all these wristbands are important."Explaining that your facility uses a different color code system, you tell her you'll be giving her a new set of wristbands. Mrs. Jones asks, "Why don't you all just use the same color scheme?"We think Mrs. Jones has an excellent idea. In fact, a national movement to standardize the color-coded wristbands used in healthcare is underway to help prevent confusion and increase patient safety. This article explains the dangers of using nonstandardized color-coded wristbands and suggestions for using colored wristbands safely.The patient safety issues of color-coded wristbands first gained widespread attention when a Patient Safety Advisory was issued by the Pennsylvania Patient Safety Authority (PA-PSA) in 2005. It was based on a report received by the Pennsylvania Patient Safety Reporting System. A patient experiencing a cardiopulmonary arrest almost wasn't rescued because the patient had mistakenly been given a yellow wristband, which signified a DNR order. The nurse who had placed the yellow wristband on the patient also worked at another hospital in the area where yellow meant "restricted extremity." Fortunately, the mistake was recognized in time and the patient was resuscitated.1Pennsylvania is unique in the nation in that a near-miss such as this, which resulted in no patient harm, is a mandatory reportable event.2 The report brought to light a problem that wasn't

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