Most Wisconsin Hospitals Adopt Standardized Color Alerts

[May 1, 2009, AJHP News]

Kate Traynor

BETHESDA, MD 15 April 2009—What's red, yellow, orange, pink, or clear? The color of wristbands used to denote an allergy risk in patients treated at Milwaukee-area hospitals before last year's launch of a statewide program to standardize color-coded patient alerts.

Now, hospitals in Wisconsin that have adopted the system use a red band to denote allergy, a yellow one for fall risk, and a purple band to indicate a do-not-resuscitate (DNR) status, according to the Wisconsin Hospital Association (WHA), which led the initiative. A white or clear wristband is used for patient-identification information.

As of March 1, more than 80% of the hospitals in the state had adopted the color-coding system.

"The goal is for all hospitals that use colors for common alerts to be using the same colors," said Dana Richardson, WHA vice president of quality initiatives. "Of the 20% that have not switched, most are working on it."

For legibility reasons, WHA recommends that only the words "allergy," "fall risk," or "DNR" appear on the alert bands. Patient-specific explanations about the alerts should be part of the medical record and readily available for all health care providers to view and update, Richardson said.

The Pennsylvania-based Institute for Safe Medication Practices (ISMP) in 2006 called for national standardization of wristband alert colors. ISMP made the recommendation after a near-miss incident in Pennsylvania where a nurse placed a yellow wristband on a patient, thinking it signaled a restriction against performing procedures on that arm, at a hospital where the color indicated a DNR status.

A group of Pennsylvania hospitals subsequently launched a wristband standardization project that has earned recognition from the federal Agency for Healthcare Research and Quality. The Pennsylvania project specifies the use of blue bands for DNR, red for allergy, and yellow for fall risk. Implementation tools have been created to help other states to craft their own programs.

Before embarking on its statewide program, WHA surveyed Milwaukee-area hospitals to see how they used color-coded alerts.

"There was huge variation," Richardson said. In all, nine colors were used at different hospitals to indicate 14 different alerts.

Now, she said, much of that variation has been eliminated, and clinicians do not need to learn a new system when they work at more than one hospital in the state. Neighboring Minnesota has also adopted the same color system for its allergy, fall risk, DNR, and patient-identification wristbands.

Richardson said pharmacists will probably find the standardized allergy wristbands particularly important. But pharmacy directors in Wisconsin say the other bands can be relevant to pharmacists.

David Grinder, director of pharmacy at Monroe Clinic in Monroe, said pharmacists are on hospital teams that respond to calls for resuscitation. "So if the pharmacist arrives, and they notice a purple [DNR wristband], they would certainly question the process and help identify what needs to be done next."

The 100-bed hospital began using the new system March 1, and Grinder said the implementation has gone "smoothly and painlessly."

Grinder said Monroe had previously used red patient wristbands to denote allergy, and fall risk was indicated by placing a leaf symbol at the patient's door.

He said the white patient-identification wristbands are critically important for Monroe because they are bar coded for use with the hospital's electronic medication administration record (MAR) system. He said the colored wristbands provide extra visual reinforcement during the medication-administration process.

For example, he said, "the red armband would just cue the nurse, physician, or pharmacist to look at their medication record to identify what those allergies are. If an order got onto the electronic MAR and that allergy warning was missed, the bar-code process would give the nurse a warning. So [now] we have two warnings."

"I think it's a benefit for anybody that interacts with the patients," Grinder said of the new wristbands.

Children's Hospital of Wisconsin, in Milwaukee, switched to WHA's color-coding system March 23.

Tom Lausten, the hospital's director of pharmacy and distribution, said getting the program under way was not the simple process that it first appeared to be.

"It's not just putting on a band; it is a little bit more," Lausten said.

Because Children's patients range in size from tiny neonates to full-grown adults, finding colored bands to fit all patients took longer than expected.

And, as at Monroe, a major concern for pharmacy was that the patient-identification bands accommodate the bar codes used with Children's bedside bar-coding system for medication administration.

Children's has implemented the state's standardized white, red, and yellow wristbands and has also adopted green wristbands to indicate that a patient is under isolation. The hospital does not use a wristband to indicate DNR status but instead has in place special procedures for working with families about end-of-life care for their children.

Sometimes, patients enter the hospital wearing their own colored wristbands—ones that indicate support for cancer research, environmentalism, or other social causes. WHA recommends that these wristbands be removed on admission to avoid confusion with the standardized alert bands.

"It would be a disaster if somebody were in a social cause that had a purple wristband, and they came to the hospital and somebody saw that and didn't call a code when they needed to," Grinder said. "So they have to come off of the patient."

Lausten said social cause wristbands seem to be popular among teenage patients at Children's, which also requires the bands to be removed or obscured with opaque tape.

Lausten said he thinks the statewide initiative will ultimately prove beneficial to patients.

"Conceptually, it's a great idea," he said. "I'm a firm believer in standardization."