A recent near-miss report submitted to the Authority through the Pennsylvania Patient Safety Reporting System (PA-PSRS) describes an event in which clinicians nearly failed to rescue a patient having a cardiac arrest because healthcare workers mistakenly believed the patients wristband color meant Do Not Resuscitate when it was actually meant to convey a different message.
The problem was caused partly by a healthcare providers confusion about the meaning of a yellow wristband, said Alan B.K. Rabinowitz, Authority administrator. In this particular facility, a yellow wristband means Do Not Resuscitate, but in a nearby facility a yellow wristband is used to mean that a patient should not have blood work or an IV placed in that particular arm.
Because the provider worked in both facilities, she inadvertently used the yellow wristband in the wrong facility. When other healthcare workers later saw the yellow wristband, they incorrectly thought the patient was designated as Do Not Resuscitate.
According to Dr. John Clarke, PA-PSRS clinical director, there are a number of steps facilities can take to make use of color-coded patient wristbands safer. Although standardizing the meaning of different colors can only be done by coordination among healthcare facilities, Clarke noted, individual facilities can limit the number and colors of patient wristbands and use printed text to reinforce the meaning of specific colors. They can also reconfirm clinical instructions with both patients and hospital staff.
To assess the potential scope of the problem, the Patient Safety Authority surveyed Patient Safety Officers in all
In a recent survey, about four out of five
There are no standard meanings among healthcare facilities for different colors.
Limiting the number of wristbands and the colors used may help to avoid confusion for healthcare providers working in multiple facilities. Printed instructions on wristbands can help to reinforce the message conveyed by a particular color.
Rabinowitz cites the usefulness of gathering reports in real time through the PA-PSRS system as a major contributor in helping improve patient safety by disseminating information about potential risks to facilities throughout the state.
The wristband issue is not one that will be resolved overnight, Rabinowitz said. However, by sending out an advisory to all healthcare facilities making them aware of the potential problem associated with color-coded wristbands in one hospital, we are giving all healthcare facilities the opportunity to implement steps to prevent a similar event from happening in their own facility.
The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error Act, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all
Facilities submit reports of serious events and incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web-based system that was developed for the Authority under a contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.
More than 230,000 reports have been submitted through PA-PSRS since mandatory reporting was initiated in June 2004. Ninety-five percent of these reports are Incidents or near-misses. Based on those reports, the Authority issues quarterly Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm. Occasionally, if a report is submitted that demands more immediate attention, a Supplementary Advisory focusing on that one particular topic will be issued.
Source: Patient Safety Authority