Although the mistake was caught in time, the incident raised the possibility of real patient harm, even death, if a wrong wristband is used. Following the incident, the Patient Safety Authority issued a special Patient Safety Advisory in December 2005 to alert the healthcare industry to this potential problem and to suggest steps facilities could take to reduce the risk of patient harm.
A group of facilities formed the Color of Safety Task Force to develop detailed protocols, including a policy manual and training resources, to reduce the risk of medical error when using color-coded wristbands. The Task Force has made the manual and related materials available to other facilities through the Patient Safety Authoritys Web site. All facilities can adopt or adapt the manual for their own use.
Bonnie Haluska, associate vice president of the Allied Services Rehabilitation Hospital in
Task Force members attended a recent board of directors meeting held by the Patient Safety Authority to update board members on its progress. Alan B.K. Rabinowitz, administrator of the Patient Safety Authority, said board members were impressed with the presentation made by the Task Force. The Authority welcomes the grassroots effort made by these hospitals to improve patient safety in their facilities, said Rabinowitz. These hospitals recognized the important lesson learned as a result of this incident, and they worked together in a collaborative fashion to establish a protocol that can also help other organizations improve patient safety in their own facilities.
Rabinowitz noted that the Authoritys goal in issuing advisories is to encourage facilities to learn from events and implement appropriate changes to prevent a similar event from happening in their own institutions. This group of hospitals rose to the challenge, Rabinowitz said, and they successfully engaged healthcare workers, patients and members of the community in this patient safety campaign.
Holy Spirit Health System (Camp Hill)
John Heinz Institute (
Source: The Patient Safety Authority