Statewide Standards for Color-Coded Wristbands Are Adopted by Vast Majority of Arizona Hospitals

Problem Addressed

• Use of multiple color codes: A 2006 survey found that Arizona hospitals used eight different colors/methods to convey a DNR order.¹ In other words, a red wristband may mean one thing (e.g., DNR) in one hospital, but mean something different (e.g., penicillin allergy) in another.
• Confusion due to high turnover rates, use of temporary staff: Because staff turnover is high in many organizations and some temporary/part-time staff may work in multiple hospitals simultaneously, individual nurses and other staff members may be exposed to multiple color-coding systems, creating confusion as to what a particular color means at a given institution.
• Potential of standardization to help: Standardization represents a fundamental concept in patient safety.² The creation of standardized color codes that can be used by hospitals throughout a state or even the nation should reduce the potential for confusion, thus reducing the risks of errors and near misses. 

Description of the Innovative Activity

• Standardized color-coded wristbands: A multidisciplinary team used a consensus process to develop the following standards:  
  • Purple to designate DNR patients: The team considered other colors, but dismissed them for various reasons. For example, green conveys “go” to most people and is not recognized by people who are color blind. In three-fourths of Arizona hospitals, blue designates a “Code Blue” situation, so using this color to designate DNR seemed counterintuitive from a human factors perspective. The team also considered use of orange, but this color was already being used as a prehospitalization designation of an Advance Directive in Arizona.
  • Red for allergy alert: A survey showed that the majority of Arizona hospitals already used a red color band to designate allergies, so it made sense to continue with an established practice. In addition, the American National Standards Institute uses red to communicate “stop” and “danger,” which is an appropriate signal to send to providers about the need to stop and check for food, drug, or treatment allergies. The workgroup further recommended that all specific allergies be written in the patients' medical record.
  • Yellow to designate a high risk of falling: The color yellow is associated with “caution” (e.g., with traffic lights) and the American National Standards Institute uses yellow to communicate “tripping or fall hazard.” Thus, it made sense to use yellow to indicate which patients may have problems with balance, dizziness, or gait, all of which can lead to falls.
• Implementation guide and toolkit: Because use of the standardized color codes is voluntary, the association's leaders encourage compliance by providing support to hospitals as they embark on the year-long implementation process, including obtaining approvals and educating staff. To that end, the association developed an implementation guide that walks a hospital through the steps needed to adopt the standards. The guide is accompanied by a toolkit that provides the following: a suggested work plan on how to implement the standards, including task charts; staff and patient educational materials and training; policies and procedures; and information on vendors that can provide the wristbands. 
• Distribution through partner organizations: To increase awareness and adoption, the kit has been distributed to associations and other organizations that have established relationships with hospitals, including skilled nursing facilities, home health agencies, and physician organizations. The kit has also been distributed to temporary nursing staff agencies so that the standards can be made a part of their staff orientation process.

References/Related Articles

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Results

• Most hospitals implementing standards: To date, 96 percent of Arizona hospitals have agreed to implement the program.
• Reports of improved safety: Anecdotal reports from staff in those hospitals adopting the standards suggest they are quite satisfied with the program and believe it is having a direct, positive impact on patient safety. Some staff noted how the standards have helped to reduce confusion about wristband colors, thus preventing "near misses" that used to occur. 

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Building consensus about the need for standardization: The association surveyed Arizona hospitals about their current use of color-coded wristbands, the results of which showed significant variation in color designations and meanings. This variation made it clear that there was a need for standardization to reduce the risk of medical errors due to confusion and miscommunication.
• Formation and operation of multidisciplinary workgroup: This team, known as the "Safe and Sound" workgroup, consisted of 12 health care professionals from throughout the State, including physicians, nurses, and representatives from various hospital departments, including pharmacy, education, risk management, quality, patient safety, and informatics. The group met four times in person over a 6-month period to forge consensus on the color standards. To assist with this process, the association conducted a literature review on human factors issues, the science of human error, and accepted color standards, including evidence and recommendations from the American National Standards Institute on the appropriate use of colors. Although the workgroup recognized that many conditions might merit use of standardized color wristbands, it chose to focus on a few critical conditions (allergies, DNR, and risk of falling) to allow for quick and easy adoption by hospitals. To assist with implementation, the workgroup also planned the celebratory launch (see below), implementation guide and toolkit, and other resources.
• Celebratory launch to encourage compliance: The association conducted a celebratory kick-off meeting to promote the program to representatives from more than 100 hospitals. To make the program fun and inspiring and to encourage a change in the traditional paradigm, association leaders chose to host the event at a local zoo. The color scheme for decorating the room included the colors of the wrist band schema. During the meeting, members of the multidisciplinary design team modeled the steps that a hospital would need to take to implement the new standards (e.g., identifying a change agent, selling the idea to key stakeholders). The meeting also included a keynote presentation by an expert in time management.
• Monitoring implementation: The Arizona Hospital and Healthcare Association surveyed hospitals in the state to determine which ones implemented the standards.

Resources Used and Skills Needed

• Staffing: In addition to the time put in by the workgroup, existing Arizona Hospital and Healthcare Association staff facilitated the initial literature review, survey, and planning process; developed the implementation guide; launched the program through a kick-off meeting; and monitored implementation.
• Costs: The total cost of the celebratory launch and the development and printing of 350 toolkits was approximately $25,000.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• At the State level, the following can assist in getting started with this program:
  • Gather baseline data: These data help to establish current practices, which is critical to establishing the need and planning the program.
  • Organize multidisciplinary team: This team, which serves as the primary workgroup, should include representatives from across the State to make sure that different perspectives are heard and addressed.
  • Support implementation: Provide hospitals with practical, easy-to-use tools to encourage adoption.
• At the individual hospital level, the following can assist in getting started with implementation of the standards:
  • Train broadly: Include all staff members who interact with patients in the training program, including unit clerks and housekeeping staff.
  • Use the toolkit: Consider following the step-by-step implementation process outlined in the toolkit.
  • Assign a leader: Designate a project manager to organize the process.
  • Create interest and buy-in: A celebratory program launch can help win the support and buy-in of key stakeholders.
  • Create a plan: Establish a methodical, realistic roll-out plan rather than imposing an artificial deadline.

Sustaining This Innovation

• At the State level, the following can assist in sustaining adherence to the standards over time:
  • Respect culture: Respect the unique cultures of hospitals, allowing them to make minor adaptations in the program. (For example, one hospital used a purple dove to designate do not resuscitate, rather than a purple wristband with the acronym “DNR.”)
  • Provide ongoing support: Resources such as a list of answers to frequently asked questions (FAQs) can be helpful. The FAQs should address common potential concerns and objections in a logical way.
  • Provide ongoing education: Separate educational pieces should be used to target the needs of different stakeholders (e.g., chief executives, medical staff, nursing).
  • Celebrate success: Share the credit and celebrate successes with all stakeholders.
  • Partner with external stakeholders: Collaborate with key organizations that can encourage implementation of and adherence to the standards, including the local Medicare Quality Improvement Organization, the pharmacy association, and the boards of nursing and medicine.
• At the individual hospital level, the following can assist in sustaining adherence to the standards over time:
  • Elicit and address nurse concerns: Pay particular attention to the concerns of bedside nurses, as they are generally responsible for adhering to the standards.
  • Consider customization: If necessary to facilitate compliance, minor adaptations can be made to reflect the unique culture of the organization (e.g., putting the hospital logo on materials, the aforementioned use of the purple dove to designate DNR).

Use By Other Organizations

• As of April 2009, 26 states have implemented standard colors for between two and five wristbands, with an additional 10 states planning some level of standard wristband implementation in 2009. A U.S. map detailing state-by-state implementation activities, updated monthly, is available at http://www.patientidexpert.com/literature_brochure.html (click on “State Color Code Implementation Map”).