WRISTBAND STANDARDIZATION

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WRISTBAND STANDARDIZATION
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The LiteratureRationale for Standardization in
other states

• A survey conducted in Arizona in March 2006
  showed that 8 different colors/methods were being
  used to convey DNR
• 60 - No Band 2 - White13 - Blue
  2 - Yellow
• 13 - Orange 2 - Green
• 6 - Purple 2 - Red

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In PA

• In 2005, clinicians nearly failed to rescue a
  patient who had a cardiopulmonary arrest because
  the patient had been incorrectly designated as
  DNR.
• Source of confusion was a nurse that had
  incorrectly placed a yellow wristband on the
  patient (which meant DNR at that hospital)
• In a nearby hospital where she also works, yellow
  meant restricted extremity which was her intent
  as an alert

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Proposed Plan for NH

• Establish small working group including CEO, CNE,
  MD, Pharmacist, quality expert, risk manager, and
  staff nurse to review whats been done already
• Reach consensus on the interest and readiness
  to propose a statewide initiative
• Recommend adoption of an existing model with NH
  specific Toolkit
• Develop a work plan and timetable for
  implementation

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It was made clear that

• The safety of patients across the state and
  success in this effort depends on the
  participation of every hospital in the state that
  uses wristbands for alerts. This will require a
  willingness to change for the greater good.

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• Rationale for banding for DNR
• Increasing number of healthcare providers are not
  hospital based, current processes need to take
  this into account. Travelers or non-clinical
  staff may be unaware of where to look in the
  medical record if they are new to your hospital
• When seconds count, having an alert wristband
  will serve as ready communication in a crisis
  situation, evacuation situation, or with patients
  in transit
• Serves as a means to communicate to the family
  that you are clear about their end of life wishes

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Rationale for purple

• Blue? Most hospitals announce a code using Code
  Blue too much potential for confusion
• Orange? Many hospitals use this color to indicate
  the presence of an Advanced Directive
• Green? Due to color blindness, avoid it

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• Why red?
• Many hospitals currently use red
• Red is used in other industries to imply extreme
  concern
• The American National Standards Institute uses
  red to communicate Stop! or Danger!
• When a caregiver sees a red band, they are
  prompted to Stop! and double check the
  medication, food, or treatment they are about to
  receive.

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Allergies written on wristband?

• NO!
• Legibility may hinder the correct interpretation
• One may assume the list is comprehensive and not
  check the medical record
• During the hospitalization, allergies may be
  discovered and added to the medical record and
  not always a wristband

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• Why Yellow?
• Other industries use yellow to imply caution
• ANSI uses yellow to communicate Tripping or
  Falling hazards
• Caregivers need to use caution with a person with
  a history of previous falls, dizziness or balance
  problems, or confusion

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Why band for Falls?

• More than a third of adults over 65 fall each
  year
• Older adults are hospitalized for fall-related
  injuries 5 times more often than they are for
  injuries from other causes
• Of those who fall, 20-30 suffer moderate to
  severe injuries
• Total projected cost of all fall injuries by
  2020, is 43.8 billion

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Risk Reduction Strategies

• Use wristbands with the alert message pre-printed
  (such as DNR)
• Remove any social causes wristband (such as
  Live Strong)
• Remove wristbands that have been applied by
  another facility
• Initiate banding upon admission, changes in
  condition, or when information is received during
  the hospital stay

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Risk Reduction Strategies

• Educate patients and family members regarding
  purpose and meaning of wristband
• Coordinate medical record/white board/care
  plan/door signage/stickers with the same color
  coding
• Verify patient color-coded alert wristbands
  upon assessment, hand-off of care and facility
  transfer communication

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4 Step Workplan

• I. Organizational Approval
• Hospitals have different committees that need to
  approve system wide changes that directly impact
  patient care. Each organization needs to assess
  which committees need to approve the adoption of
  the initiative and begin to get on meeting
  agendas for approval. These committees could
  include Patient Safety Committee, Quality
  Improvement Council, Medical Staff Committee, and
  Board of Directors.

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Workplan

• II. Supplies Assessment and Purchase
• Some New Hampshire hospitals may have a vendor
  they use to order wristbands. The Foundation
  for Healthy Communities will contact them and
  arrange for the standardized bands to be
  available. Coordinate with your Materials
  Management department to evaluate when current
  stock will be used up. Once this is known, the
  rest of this implementation plan will back fill
  into this date.

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Workplan

• III. Hospital Specific Documentation
• Color-banding policy should be reviewed and
  approved if changes are made.
• Hospitals should review their respective forms
  for possible modifications (pt. education
  assessments, etc.) You may want to include
  language that the patient received the wristband
  education brochure.
• If a patient refuses to wear a band, you need to
  document this.

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Workplan

• IV. Staff and Patient Orientation, Education and
  Training
• Hospitals need to develop staff educational
  material and coordinate training sessions and
  competency forms for employees. Consider all of
  the stakeholders in your hospital when it comes
  to color-coded wristbands and who is impacted in
  this system change. For example, while
  ultimately the nurses are the people that usually
  band the patient, the health unit clerks,
  housekeeping staff, dietary staff, and medical
  staff should be considered when planning
  educational sessions.
• Hospitals should also develop education materials
  for patients and families.

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Policy name Color-coded Wristbands

• Purpose
• To have a standardized process that identifies
  and communicates patient specific risk factors or
  special needs by standardizing the use of
  color-coded wristbands upon the patients
  assessment, wishes, and medical status.
• Objectives
• To reduce the risk of potential for confusion
  associated with the use of color-coded
  wristbands.
• To communicate patient safety risks to all
  health care providers.
• Definitions
• The following represents the meaning of each
  color-coded band
• Red Allergy
• Purple Do Not Resuscitate
• Yellow Fall Risk

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Options for banding
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Patient Refusal form

• Patient Refusal to Participate in the Wristband
  Process
• Name_____________________________________________
  ____
• PID________________________________________
• DOB_______________________________________
• The above named patient refuses to (check which
  applies)
• ? Wear color coded alert wristbands.
• The benefits of the use of color coded
  wristbands have been explained to me by a member
  of the health care team. I understand the risk
  and benefits of the use of color coded
  wristbands, and despite this information, I do
  not give permission for the use of color coded
  wristbands in my care.
• ? Remove Social Cause colored wristbands (for
  example Live Strong and others).
• The risks of refusing to remove the Social
  Cause colored wrist bands have been explained to
  me by a member of the health care team. I
  understand that by refusing to remove the Social
  Cause wristbands could cause confusion in my
  care, and despite this information, I do not give
  permission for the removal of the Social Cause
  colored wristbands.
• Reason provided (if any)_________________________
  ________________________________
• __________________________________________
  ___________________________________
• _____________________ ___________________________
  _____________________ Date/Time
  Signature / Relationship

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Patient Safety Information Script for use in
brochures or in-hospital television

• New Hampshire healthcare providers are working
  together to make New Hampshire the safest state
  in the nation. We accomplish this goal by
  working together on statewide projects in an
  endeavor to use the same methods or processes,
  like color-coded wristbands.
• Our hospital is proud to be a supporter of this
  collaborative work, making healthcare safer and
  better for patients and their families.
• Statewide Patient Safety Initiatives
• New Hampshire has a goal of being the safest
  state in the nation. We accomplish this in
  several ways, one which includes using the same
  colors for alert wrist bands.
• What is a Color-coded Alert Wrist Band?
• Alert wristbands are used in hospitals to
  quickly communicate a certain health care status
  or an alert that a patient may have. This is
  done so every staff member can provide the best
  care possible, even if they do not know that
  patient. The different colors have certain
  meanings. The words for the alerts are also
  written on the wristband to reduce the chance of
  confusing the alert messages.
• What do the different colors mean?
• There are three different color-coded alert
  wristbands that we are going to discuss
• because they are the most commonly used in New
  Hampshire hospitals. RED means ALLERGY ALERT
• If a patient has an allergy to
  anythingfood, medicine, dust, grass, pet hair,
  ANYTHINGtell us. It may not seem important to
  you but it could be very important in the care
  they receive.
• PURPLE means DNR or Do Not Resuscitate
• Some patients have expressed an end-of-life wish
  and we want to honor that.
• YELLOW means FALL RISK
• We want to prevent falls at all times. Nurses
  review patients all the time to determine if they
  need extra attention in order to prevent a fall.
  Sometimes, a person may become weakened during
  their illness or because they just had a surgery.
  When a patient has this color-coded alert
  wristband, the nurse is saying this person needs
  to be assisted when walking or they may fall.

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Staff Competency Checklist
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Sample Poster - Wristbands
Name of Hospital is committed every day to
providing safe patient care. This means that if
you suffer from an allergy, are at risk for
falling, or have chosen not to be resuscitated,
you will be asked to weara wristband as an alert
to those caring for you.

RED Allergy

PURPLEDo Not Resuscitate
YELLOWFall Risk
If you have any questions about this safety
practice, please ask your nurse or call...

Hospital logo
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Patient Safety Tri-Fold
Patient SafetyUnderstandingwhat your
color-coded alert wristbands
mean Insert Hospital Logo
New Hampshire healthcare providers are working
together to make New Hampshire the safest state
in the nation. We accomplish this goal by
working together on statewide projects in an
endeavor to use the same methods or processes,
like color-coded wristbands The Foundation for
Healthy Communities wishes to acknowledge the
Arizona Hospital and Healthcare Association which
developed the initial handout.
Our hospital is proudto be a supporter of this
collaborative work, making healthcare safer and
better for patients and their families.
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Staff Education Tri-Fold
What about New Hampshire?New Hampshire
has a goal of being the safest state in the
nation. We accomplish this in several ways, one
which includes using the same colors for alert
wristbands. All hospitals in New Hampshire are
adopting the same colors so regardless of which
hospital you work at today or tomorrow, the
color-coded alert wristbands should be the same
color for Allergy, the same color for Fall Risk
and the same color for Do Not Resuscitate. RED
means Allergy Alert YELLOW means Fall
Risk PURPLE means DNR The Foundation for
Healthy Communities wishes to acknowledge the
Arizona Hospital and Healthcare Association which
developed the initial handout.
How this all got started In 2005, a hospital in
Pennsylvania submitted a report to the
Pennsylvania Patient SafetyReporting System
(PA-PSRS) describing an event in which clinicians
nearly failed to rescue a patient who had a
cardiopulmonary arrest because the patient had
been incorrectly designated as DNR (do not
resuscitate). The source of the confusion was
that a nurse had incorrectly placed a yellow
wristband on the patient. In this hospital, the
color yellow signified that the patient should
not be resuscitated. In a nearby hospital, in
which this nurse also worked, yellow signified
restricted extremity, meaning that this arm is
not to be used for drawing blood or obtaining IV
access. Fortunately, in this case, another
clinician identified the mistake, and the patient
was resuscitated. However, this near miss
highlights a potential source of error and an
opportunity to improve patient safety
byre-evaluating the use of color-coded
wristbands. We want to thank and acknowledge
this hospital for their transparency and
disclosure of this event. It could have happened
anywhere, and it has served as a wake up call
to many of us.
Staff Education Regarding Color-coded alert
wristbands Information intended for all
staff, clinical and non-clinical Insert Hospital
Logo

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Frequently Asked Questions

• Back in the day, we never used wristbands. Why
  should we consider it?
• While there is much discussion regarding the
  issue of to band or not to band, a literature
  review to date has not identified a better
  intervention. One may say, In the good old
  days, we just looked at the chart and didnt band
  patients at all. However, those days consisted
  of a workforce base that was largely core staff
  employed by the hospital. Now, an increasing
  number of healthcare providers are not hospital
  based staff, so it is imperative that current
  processes take this into consideration.
• We dont use wristbands for DNRs. Why adopt
  this?
• Wristbands are used in most NH hospitals to
  communicate an alert. Registry staff, travelers,
  non-clinical staff, etc. may be unaware of where
  to look in the medical record if they are new to
  your hospital. By wearing a wristband, a quick
  warning is communicated to caregivers.
  Additionally, it is also a means to communicate
  to the family that we are clear about their end
  of life wishes. By not wearing a band, errors of
  omission could potentially occur.

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Frequently Asked Questions

• So, if we adopt the purple DNR wristband then do
  we still need to look in the chart?
• Yes. Code status can change throughout a
  hospitalization. It is important to know the
  current status so the patient and family wishes
  can be honored. Always validate that there is an
  order by a physician for the DNR designation.
• Does the use of the wristband for DNR create a
  stigma?
• It shouldnt if the material is presented in a
  sensitive manner. One suggestion is that
  patients be told that we designate a DNR status
  so we can honor patients and their loved ones in
  the end of life wish. To that end, comfort and
  honoring that wish still requires time, attention
  and care and we are committed to providing that
  level of care.

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Frequently Asked Questions

• Will people be concerned that they or their
  family member wont get the care that they
  receive if they are wearing a DNR band?
• A good answer to that concern is that the care
  doesnt go away it is just different. To
  provide comfort and dignity to a patient during
  this time is just as time consuming, and in some
  cases, even more so because it is the human
  touch, the hands on type of care that is often
  required.
• What if hospitals are already using the Braslow
  System for pediatric patients? Wont it cause
  confusion? The Braslow system does not use the
  same tones/hues that are being standardized for
  the three safety alerts in New Hampshire
  hospitals. The wristbands will look distinctly
  different. Also, it would be rare that a child
  would need a fall or DNR alert band.
  
  

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Frequently Asked Questions

• Wont there be confusion between a red allergy
  alert wristband and the red band used by the
  blood bank?
• Many states have already dealt with this same
  issue and have concluded that even though the
  blood bank wrist band is red, the band looks very
  different because of the information written on
  it, i.e. a unique identifier (matching the blood
  products), the patient name, medical record ,
  physician, and date of birth.
• What are the implications in terms of public
  perception if some hospitals dont voluntarily
  adopt standardized wristbands?
• Hospitals should evaluate why they would not
  standardize the colors used for safety alert
  wristbands if they use them currently. If they
  have sound reasoning, they will be able to answer
  their communitys concern without any problem. If
  however, a hospital does use wristbands and has
  decided to stay with the same colors they have
  always used while most of the other New Hampshire
  hospitals are adopting the standardization it
  will be tough for them to answer that question.

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New Hampshires hospitals band together for
patient safety

• November 18, 2008
• CONCORD Continuing its work in promoting
  better patient safety practices across New
  Hampshire, the Foundation for Healthy
  Communities, in partnership with the New
  Hampshire Organization of Nurse Leaders, has
  launched a major statewide initiative to
  standardize color-coded wristbands in hospitals
  which use them. Those hospitals will voluntarily
  adopt the color system by January 1, 2009.
• Wristbands often are used to convey specific
  information to physicians and nurses about a
  patients care. Each color signifies a
  particular care directive or alert, such as
  whether a patient has a medical allergy. But the
  system meant to keep patients safe could have
  unintended consequences if caregivers arent
  clear about the meanings behind the colors.
• Many doctors, nurses and other practitioners
  work in more than one facility, each with its own
  set of wristband colors, said Diane Allen, who
  co-chaired the Foundations wristband
  standardization initiative and is Chief Nursing
  Officer at Concord Hospital. Confusion among
  providers is avoidable if hospitals use the same
  colors to represent the safety alerts.