Does your patient have a drug or food allergy?
In December 2005, the Pennsylvania Patient Safety Authority issued a patient safety advisory that received national attention. In a Pennsylvania hospital, clinicians nearly failed to rescue a patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as Do Not Resuscitate (DNR).
The source of confusion was the patient’s wristband.
A nurse had placed the wrong color wristband on the patient. In that hospital, a yellow wristband meant DNR. In a nearby hospital, where the nurse also worked, yellow meant “restricted extremity,” which was what she intended to indicate. Fortunately, in this case, another nurse recognized the mistake and the patient was resuscitated.
In response to this incident, Pennsylvania became the first state in the nation to implement voluntary guidelines for standardization of colored wristbands for six clinical conditions (allergy-red, fall risk-yellow, latex allergy-green, DNR-blue, patient identification-clear and limb alert-pink). Immediately following in Pennsylvania’s footsteps were Arizona, Iowa, Michigan, Minnesota, Florida, Colorado, New Jersey, just to name a few, all of which initiated the effort to standardize communication for patient risk factors and special needs before patient harm occurs.
The Maryland Hospital Association’s Council on Clinical and Quality Issues, as well as the Maryland Patient Safety Center’s Patient Safety Officers Forum, support adoption of a standardized wristband color to designate a defined set of patient safety risks. At AAMC, we are starting with the red allergy band, effective Nov 30. Other bands will follow in the near future.
-Nia Wright, MSN, RN, CNOR
A big thank you to Katie Boston, Jessica Davis, Amy Kohler, and Nia Wright for their commitment to this initiative.