Care For PA

In Pennsylvania last year, a patient almost died when a nurse misinterpreted the meaning of a colored wristband the patient was wearing. The mistake occurred because the nurse worked at several area hospitals and got the colors mixed up since each color meant a different thing at each hospital. Though the mistake was caught in time, the close call provided an opportunity for hospitals to evaluate and improve their patient safety measures. And that's exactly what happened.

Pennsylvania hospitals are not required to use color-coded wristbands to communicate important information, such as whether a patient is allergic to a drug; however, a survey last year by the Pennsylvania Patient Safety Authority (an independent state agency that works to reduce and eliminate medical errors) found that color-coded wristbands are widely used in Pennsylvania health care facilities. The meanings of the colored wristbands vary, creating a potential for confusion and health risks. These risks could be increased because nurses often work in several hospitals, and some hospitals have to rely on traveling nurses (both of whom may find different wristband colors and meanings at different hospitals). Further complicating the situation are patients who wear their own colored wristbands, such as the popular yellow "Livestrong�? bracelets worn in support of cancer survivors.

When the Patient Safety Authority's survey results were shared with Pennsylvania's hospital community, a group of 11 hospitals in northeastern and central Pennsylvania formed a task force to sort out the risks associated with the colored wristbands, develop a plan to reduce those risks, and work with patients and the community to implement the plan.

Among the safe practices the hospitals have adopted are:

• Limiting the number of color-coded wristbands and standardizing the meanings associated with each color so that they mean the same thing in each of the 11 hospitals.


• Purchasing wristbands with preprinted, embossed text, rather than relying solely on color to communicate their meaning.


• Avoiding handwriting on the bands except in emergency situations.


• Allowing only nurses to apply or remove wristbands.


• Ensuring labels and stickers used in patients' medical records correspond with the colors and meanings used on the wristbands.


• Asking that patients remove or allow hospital staff to cover up any personal wristbands that could create confusion.

The hospitals also have taken a number of steps to include patients, their families, and the community in addressing the issue. For example, the hospitals have developed a system where during the admission process, patients are educated about the reason for applying the wristbands, the meanings of the different wristbands, the need to wear the wristbands throughout their stay, and the risks associated with wearing their own wristbands. The information also is put into a brochure that can be given to the patient to keep throughout their stay. Many members of the community also have been informed about the changes through letters to community leaders and other health care providers, as well as stories in local newspapers.

The Pennsylvania Patient Safety Authority has applauded the hospitals' work. "This group of hospitals rose to the challenge, and they successfully engaged healthcare workers, patients and members of the community in this patient safety campaign.�? The Authority has posted the hospitals' recommendations on its website for all hospitals to consider. The Authority also reports that news of the hospitals' efforts has spread and sparked the interest of facilities across the state and nation.

The Pennsylvania health care organizations involved in the Color of Safety Task Force include:

• Allied Services Rehabilitation Hospital (Scranton)
• Community Medical Center (Scranton)
• Holy Spirit Health System (Camp Hill)
• John Heinz Institute (Wilkes-Barre)
• Marian Community Hospital (Carbondale)
• Mercy Hospital (Scranton)
• Mid-Valley Hospital (Peckville)
• Moses Taylor Hospital (Scranton)
• Pocono Medical Center (East Stroudsburg)
• Tyler Memorial Hospital (Tunkhannock)
• Wayne Memorial Hospital (Honesdale)

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