The Color-Coded Wristband Saga

Last week’s New York Times front-page piece on colored wristbands highlighted an issue I’ve been fretting about for years. We can achieve consensus on a $700B bailout in 3 days (well, perhaps not), but can’t agree on what color a DNR wristband should be? Wow.

My interest in this subject began with a remarkable case I first described in Internal Bleeding and later in Understanding Patient Safety. The story went like this:

A young nurse in a teaching hospital goes in to visit her patient, an elderly man on the ortho floor, and finds him not breathing. She calls for a Code Blue, and the cavalry soon arrives and begins CPR. As the Code proceeds, the team leader repeatedly asks whether anybody knows the patient’s history, to no avail.

A young resident, trying to be helpful, dashes off the nurse’s station and grabs the patient’s chart. A moment later, he slides into the room and, to the horror of the Code Blue team, breathlessly announces that the patient has a DNR order in the chart. The Code is aborted, the patient left to die.

The patient’s young nurse was there for the Code and wondered about the DNR – after all, she had received sign-out an hour earlier, and was told the patient was a Full Code. But the young resident had spoken so forcefully, she was too intimidated to speak up. “Somebody must have changed the patient’s code status and not told me,” she thought sheepishly. Chalk it up to experience.

The nurse remained in the room, helping to clean up. She palpated her patient’s radial pulse, and felt his heartbeat slow and then extinguish, like the embers on a doused campfire. Her eyes wandered to the chart, where the page with the DNR form was open. “Oh my God,” she shrieked, “that’s not this patient.” The resident, you see, had inadvertently picked up the wrong chart out of the nurse’s station chart rack.

The Code Blue team was re-called to the room, but it was too late. The patient died.

I’ve recounted this story scores of times in talks, often ending my presentation by asking the audience how this tragedy might have been averted. “Color code the wristbands,” somebody usually shouts. Seems straightforward enough. So my colleague Niraj Sehgal and I set out to study whether hospitals had implemented this simple and elegant safety solution. We published our findings last year in the Journal of Hospital Medicine.

We surveyed 127 nursing executives at academic medical centers; 69 (54%) completed the survey. They reported that 17 of their hospitals were using color-coded wristbands to identify DNR status. Of these, 8 different color schemes were described. The colors (with the number of hospitals using each color for DNR) were:



  • Green—5
  • Yellow—3
  • Blue—3
  • White with blue stars versus green stars (full DNR versus limited DNR)—1
  • Red—1
  • Red and white—1
  • Purple—1
  • Gold—1
  • Other (not listed)—1


According to the Times article, purple is now the color recommended for DNR in New York public hospitals. Hospitals have shied away from using blue, since it seems like a mixed message for a blue wristband to signify “No Code Blue.” I was pleased to see that no one was using black – that does seem a bit macabre.

Note that yellow was tied for the second most common color. This too is a bit problematic, since about 10 million people wear those cool Lance Armstrong Livestrong bracelets. A couple of years ago, a Florida newspaper reported a few near misses in which Livestrong bracelet wearers were nearly made “No Code” against their will.
 
We next asked the nurse leaders whether any other colors had meanings at their hospitals besides DNR. We found that there were 12 other color codes (I’ve since heard even more, including bladder training [yellow, obviously], diabetic, and seizure disorder). But the list from our paper (number in each category or color is in parentheses) is pretty impressive as is: 


  • Drug/allergy (22): Red (16), Yellow (4), White (1), Orange (1)
  • Fall risk (18): Orange (5), Green (3) (and lime green [1]), Blue (3), Purple (3), Yellow (2) (and fluorescent yellow [1])
  • Same name alert (7): Blue (3), Orange (2), Yellow (2)
  • Bleeding risk (3): Red (all)
  • Patient identification (3): Green, Red, White
  • Wandering risk (3): Pink (2) (and hot pink [1])
  • Contact isolation (2): Green (all)
  • Latex allergy (2): Purple (all)
  • No blood draws on this arm (1): Orange
  • MRSA infection (1): Green
  • No blood products (1): Red
  • Sleep apnea (1): Purple


Obviously, before long, the wrist of a patient unfortunate enough to have several problems begins to look like a Benetton ad.



More than 70% of the nurse executives recalled situations in which confusion over DNR status, sometimes involving the wristbands, placed patients at risk. Representative problems included:

The patient had a DNR order written in the chart but no other identifiers at bedside, so a consult service started CPR while trying to determine code status.

Prior to implementing the wristbands, there were delays in care. Once wristbands were implemented with stars only, there was confusion as to what a blue star meant and what a green star meant (limited versus no resuscitation efforts).

We used to place a sticker on the chart. A sticker was left on the chart of a discharged patient when a new patient was admitted. The mistake was caught before an incident occurred.

The situation depicted in our article and the NY Times piece might be amusing if it wasn’t so scary, and so emblematic of many of our safety problems.

I know that everybody is worried about too much standardization (“we’re different here at Acme Hospital”), and healthcare has a lot of bright people who have their own ideas about things like wristband colors. But the first principle of safety is to standardize what you can. The Times article describes a rather silly controversy over some of the colors and the language. Should a DNR wristband be purple or another color? Should it say “DNR” on it (along with being color-coded), or would that be too stigmatizing? Despite efforts in many states to standardize colors, these and similar small-bore disputes have blocked a uniform solution.

So what, you might ask? Problem is, with all these colors and indications, the chances that a nurse or doctor will forget what a given color means in the heat of battle are unacceptably high.

This struggle to “get to yes” on something as simple as wristband colors brings to mind my favorite saying about medical staffs: What do you call a 99-to-1 vote of the medical staff?  The answer: a tie. Start with this unrealistic need for complete consensus, stir in a bit too much sensitivity to patients’ privacy and to the newfangled goal of “patient-centeredness,” and you have a formula for perpetual inaction.

Folks – let’s just chose a set of colors and enforce them as national standards – stat. The Joint Commission should convene a group of safety experts, a few providers, a couple of human factors mavens, and some patient advocates, and keep the door locked and the vino flowing until they’ve hammered out an agreement. I remember when JCAHO released the list of “Do Not Use” abbreviations for prescriptions a few years ago. Sure, the list wasn’t exactly the one we would have developed ourselves, but having a national list probably saved us 10,000 hours of medication safety committee meetings – which is what it would have taken to hammer out our own list. More importantly, a uniform national list facilitated adherence: a resident who learned the list at UCSF didn’t have to relearn it when she started her fellowship at Duke; ditto a registry nurse working at several different hospitals.

So let’s create – and enforce – a national standard for wristband colors ASAP. Lives will be saved. And the Customization Police will get over it eventually.

7 Responses to “The Color-Coded Wristband Saga”

  1. PFJ September 30, 2008 at 6:14 am #

    (1)  When you say “we,” perhaps it would be a good thing to define just who you mean.  I prefer to say “they” — because *I* am not the problem, with a lot of these issues.

    (2)  Is it necessary to have one more bracelet?  How much would it cost to add an RF chip to the existing I.D. bracelet?  Perhaps some sort of fold-over add-on device… so that the privacy issues which are associated with passports don’t occur.

    Anything but one more bracelet.  They aren’t working, because they have been way overdone.

  2. Robert in Portland September 30, 2008 at 8:02 pm #

    I grew up knowing that I could not be a telephone lineman or airline pilot becasue of my color blind eyes. Now I won’t even be able to determine a patient’s code status! Seriously, while I totally agree with the idea of a national standard, include experts in color vision in selecting the proper color. For those of us who are red/green color blind, the thought of telling if a wristband is purple or blue is scary!

  3. menoalittle September 30, 2008 at 9:58 pm #

    Bob,

    As nurses and doctors spend more time with computers than with patients, know less of the patients than of the computers, and medical care in absentia becomes the standard, it is required more now than ever that old fashioned yet “high tech”nicolor work-arounds and new policies are needed to solve the patient safety dillemmas created by these industry deemed safe machines.

    Why not take further advantage of the incredible industry trumpeted safety virtues of EMR and CPOE devices and simply make it a standard of care to have a computer terminal in each room with a color code appearing upon sign-on to assist each healthcare professional in remembering what each bracelet color means? Next to each patient’s name on the list could be placed a colored dot to match the color of the jewelry, kind of what they do for the potency spectrum of computer generated decision support pop-ups.

    In addition, studies should be carried out to determine if a color coded necklace or chest tatoo is more visible to the health care professional who starts CPR. To assure accuracy and compliance of healthcare professionals adorning patients with the correct jewelry, the hospital can hire the remote movie camera services (hope they do color) of Arrowsight Medical with consultative help from Leapfrog and its former CEO.

    If these solutions are too high tech, the bailout solution from the highways and byways is green for go and red for stop. Progress is being made! Patients will no longer be just a (room) number. They will be a color….but the gown and IV tubing should match.

    Best regards,

    Menoalittle

  4. jfsucher October 1, 2008 at 4:26 pm #

    Bob, what are you doing? You lay out a great summary of the problem. You elucidate that adding more bracelets to more wrists is a clumsy and ultimately short cited solution. Then you finish with ‘lets standardize the color scheme’. Geeze. You’re smarter than that! This problem isn’t going to be solved with standardization of a color scheme, because we have a gazillion bracelets on people throughout our hospitals. And last time I was in my ICU (a few minutes ago), I had patients changing their code status about as much as you change your socks (I hope every day).

    This problem comes back to effective ways of providing overall “situation awareness” that is complete and transparent. We need to invest in improved EMR systems that are standardized. These systems must be built with more human factors engineering involved (I detest most of the current EMRs that slap the face of standardization, and look like some government engineer designed them). Just imagine a day where you can walk into a room, and on the wall is everything that you need to know about your patient. No running to pick up a chart at the nurses station, no question about colors. Just the facts Ma’am, presented in a way that is immediately interpretable. It’s possible. Just give me a few good people, a budget, and a bit of time. 

    Thank you,

    Joe Sucher

  5. bonnie haluska October 7, 2008 at 7:19 pm #

    I appreciate your efforst to have the color band issue resolved.I proudly served as chair of an eleven hospital group who came together as the first group in the nation to standardize these colors and have our work published for all others to adopt or adapt. We implemented the process in NE Pa with great success. Our toolkit has been used as a framework for states including Arizona, Ca, Ny, etc. I can tell you the process works. Our doctors are happy with the ease of it. The bands are embossed for those with color-blindness. Bands stay on for hospital to hospital transfers thereby improving hand-off communication and reducing falls and mis-use of restricted extremities. Pink bands alert docs in imaging and dialysis centers, ambulance crews, etc- not to use “shunt bearing ” arms or limbs affected by lymphedema. Patients ask for the pink bands to take home- afraid that someone will not listen to them but see the warning they bear. Our nurses amd staff who work between hospitals are no longer afraid that they will make a mistake – cautions are visible and familiar. We worry about what patients will say about wearing bands- but we worry needlessly. Patients are ASKED if they will wear the bands, they are not forced upon them. Our committee invited ex-patients to serve with us and patients always said- “If it is my choice- I don’t care who knows it”. What good are signs or charts if the information is not readily available to overworked doctors and nurses? Patients travel throughout hospital floors and departments- are we that great in hand-off communication? Have you ever grabbed the arm of a patient and then realized that you were not to use that extremity for BPs or lab sticks? How quick do you idenitfy patients with latex allergies? Med or food Allergies? Wouldn’t it be much more effective if you saw and interpreted : yellow- caution red- stop green- environment purple- DNR pink- Komen … we thought this made sense and we know it works. Help us spread the word. Our toolkit is on the JCAHO International Safety website- we do not force anyone to use bands if they do not already use them- but ask that they use these colors ONLY for the meaning we describe. We can then all “band together” for patient safety across the nation.

  6. Benjamin Littenberg October 9, 2008 at 1:26 am #

    Color coding has a long and sad history in the safety world, as illustrated by the problems in labeling medical gasses. Threats to its validity as a high-reliability signal include:
    poor lighting
    color blindness
    wear-and-tear on the colored item (think compressed gas tanks that have all the paint scraped off while banging around the back of a truck)
    limited band width (there are hundreds of compressed gasses, just as there are hundreds of patient states with subtle differences)
    competing standards (oxygen is green in the US, but white overseas)
    printing and reproduction issues (its hard to get every batch of bracelets the same shade of blue as every other)
    fading over time
    color change when wet
    False sense of security which may result in failure to “Read the label.”

    There is a (very) little bit of evidence on the real-world effectiveness of color-coding. For instance, the AMA reviewed color coding of pharmaceutical packages in 2004 (http://www.ama-assn.org/ama/pub/category/13662.html).

    Are there any data on the use of color-coded wrist bands to identify patient characteristics?

  7. P Mann May 3, 2010 at 10:56 pm #

    My focus is to add a bracelet as a method to identify a patient, where ever they go in the hospital/facility, of their DNR, Fall, Medication and now, Pressure Ulcer status. We have patients who go to dialysis or radiology, or even out to the chemotherapy center and are never turned. These patients have thinned charts due to computerization. The pressure ulcer identification needs to be visible to even the transporters, to enable them to be more proactive in off-loading and protecting the skin.

    What other way is available, that anyone can see at a glance, what this patient’s status is?

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