* There are no standard meanings among healthcare facilities for different colors.
* Limiting the number of wristbands and the colors used may help to avoid confusion for healthcare providers working in multiple facilities.
* Printed instructions on wristbands can help to reinforce the message conveyed by a particular color.

Rabinowitz cites the usefulness of gathering reports in "real time" through the PA-PSRS system as a major contributor in helping improve patient safety by disseminating information about potential risks to facilities throughout the state.
"The wristband issue is not one that will be resolved overnight," Rabinowitz said. "However, by sending out an advisory to all healthcare facilities making them aware of the potential problem associated with color-coded wristbands in one hospital, we are giving all healthcare facilities the opportunity to implement steps to prevent a similar event from happening in their own facility."

For a copy of the Supplementary Advisory on wristbands go to http://www.psa.state.pa.us/psa/lib/psa/advisories/v2_s2_sup__advisory_dec_14_2005.pdf


About PSA
The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error ("Mcare") Act, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all Pennsylvania hospitals, birthing centers and ambulatory surgical facilities are required to report what the Act defines as "serious events" and "incidents" to the Authority, making Pennsylvania the only state in the nation to require the reporting of both actual events and "near-misses." More than 440 healthcare facilities are subject to Act 13 reporting requirements.

Facilities submit reports of serious events and incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web-based system that was developed for the Authority under a contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.

More than 230,000 reports have been submitted through PA-PSRS since mandatory reporting was initiated in June 2004. Ninety-five percent of these reports are Incidents or "near-misses." Based on those reports, the Authority issues quarterly Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm. Occasionally, if a report is submitted that demands more immediate attention, a Supplementary Advisory focusing on that one particular topic will be issued.

For more information on the Patient Safety Authority, PA-PSRS or previous Patient Safety Advisories, visit the Authority's website at www.psa.state.pa.us.

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