HARRISBURG, PA., December 14, 2005 -- A patient nearly died recently in a Pennsylvania hospital due to confusion caused by color-coded wristbands, prompting the Patient Safety Authority to issue a Supplementary Advisory on the risks associated with using a specific color to convey clinical information.

A recent "near-miss" report submitted to the Authority through the Pennsylvania Patient Safety Reporting System (PA-PSRS) describes an event in which clinicians nearly failed to rescue a patient having a cardiac arrest because healthcare workers mistakenly believed the patient's wristband color meant "Do Not Resuscitate" when it was actually meant to convey a different message.

"The problem was caused partly by a healthcare provider's confusion about the meaning of a yellow wristband," said Alan B.K. Rabinowitz, Authority administrator. "In this particular facility, a yellow wristband means `Do Not Resuscitate,' but in a nearby facility a yellow wristband is used to mean that a patient should not have blood work or an IV placed in that particular arm."
Because the provider worked in both facilities, she inadvertently used the yellow wristband in the wrong facility. When other healthcare workers later saw the yellow wristband, they incorrectly thought the patient was designated as "Do Not Resuscitate."

According to Dr. John Clarke, PA-PSRS clinical director, there are a number of steps facilities can take to make use of color-coded patient wristbands safer. "Although standardizing the meaning of different colors can only be done by coordination among healthcare facilities," Clarke noted, "individual facilities can limit the number and colors of patient wristbands and use printed text to reinforce the meaning of specific colors. They can also reconfirm clinical instructions with both patients and hospital staff."

To assess the potential scope of the problem, the Patient Safety Authority surveyed Patient Safety Officers in all Pennsylvania hospitals and ambulatory surgical facilities (ASFs). The 139 survey respondents represented one-third of these healthcare facilities. The results of the survey and improvements that can be made to minimize patient risk when using color-coded armbands are included in a Supplementary Advisory published this week by the PA-PSRS program.

Highlights of the Supplementary Advisory include:

* In a recent survey, about four out of five Pennsylvania facilities responding use color-coded patient wristbands to communicate important medical information.

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