Fall Risk

The Color of Safety
Indiana Hospital Association
Color-coded Wristband Alert Standard
Impetus for Standardization
• Pennsylvania – wrong color Do Not Resuscitate band
applied by nurse who works in two different hospitals with two
different protocols
• Multiple states initiated standardization efforts over past
several years.
• American Hospital Association issued advisory on September
4, 2008 recommending standardization to 3 colors –
• Red for allergies
• Yellow for falls risk
• Purple for DNR
• December 2005
– Pennsylvania Patient Safety Authority (PSA) released an
advisory about a recent “near-miss” report involving
confusion caused by color coded patient wristbands
– Clinicians almost failed to resuscitate a patient in
cardiopulmonary arrest because that patient was
incorrectly designated as Do Not Resuscitate (DNR)
Source: Pennsylvania Patient Safety Reporting System (PA-PSRS). Color-coded patient wristbands
create unnecessary risk. Supplementary Advisory. 14 Dec 2005;2(S2):1-4.
Background (cont.)
• Lack of consistency in the meaning of color coded patient
wristbands problematic:
– Patients being transferred among hospitals
– Patients under the care of clinicians who work in multiple
• Pennsylvania case
– Mistake quickly realized and patient was rescued
National Survey
• American Society for Healthcare Risk Management (ASHRM):
– Leader in wristband color coding national initiative
– Nation-wide survey in 2007
• 50 states
• 4 others (e.g. D.C. & Military Health Services)
– 100% response rate
Source: American Society for Healthcare Risk Management (ASHRM). Color Coding Wristbands: A
Nationwide Practice Survey.
National Survey (cont.)
• Survey results:
– 60% of the survey population:
• Actively discussing
• Developed/developing a model, or
• Have adopted existing model
– Color coded wristbands are used most frequently for DNR,
Allergy and Fall Risk categories
National Survey (cont.)
• Allergy
– National color acceptance of RED
• Fall Risk
– National color acceptance of YELLOW
– Most variation (e.g. PURPLE & BLUE)
• Restricted Limbs
– Moderate color acceptance of PINK
• Latex Allergy
– Moderate color acceptance of GREEN
Indiana Survey
• 2/08
– Surveys sent out to Patient Safety Officers and Chief Nursing
• 93 hospitals responded
• 73.6% of hospitals use color coded patient wristbands
• 72.9% of hospitals do not emboss or imprint the risk/condition
on the band
Indiana Survey Summary
• Significant variation in Indiana hospitals regarding use of color
coded patient wristbands:
– DNR and Fall Risk represented 9 ways
– 39% use red for Allergy
– Latex Allergy represented 10 ways
– 69% use no bands for Restricted Extremity
– 74% use white bands for Patient ID
Indiana Hospital Association Action
• Council on Quality and Patient Safety
– Discussed issues related to lack of national or state standard on the
use of wristband colors at February 2008 meeting
– Council recommended delaying action until national
recommendations were available
– Sent a recommendation to the IHA Board of Directors for wristband
standardization in Indiana in September 2008 after AHA advisory
• IHA Board of Directors
– Approved a resolution and Council recommendations in November
Assessment of Current Environment
• Patient safety is a key focus in all Indiana health care facilities
• Significant variation exists in hospitals
• Confusion with social cause wristbands
• Health care staffing and patient movement
– Physicians and staff working at multiple organizations
– Agency nurses and other staff
– Multiple state system hospitals and hospitals near state borders
– Patient transfers
• Human factors research supports standardization
Standardization by State 2/09
Implemented at least
2-5 standard colors
Standardizing in 2009
No standardization or
plan of standardization
• Safety is a key priority for Indiana health care organizations
– Near misses have been reported in other states
– Many Indiana systems/regions are interested in standardizing
communication about patient information and risks
• Not all Indiana hospitals use color as a safety alert
• For hospitals that do use color as a safety alert, there is
significant variation
• Many of our neighboring states have already adopted or are
considering wristband color standards
Indiana Hospital Association
The Board of Directors of the Indiana Hospital Association recommends that
all hospitals evaluate methods to effectively communicate patient information
and risks. The use of wristband colors for patient alerts is not required, but If
an organization elects to use color-coded alerts to communicate patient
information or risks, the Association encourages Indiana hospitals to use the
following colors:
Red - Allergy
It is recommended that if a hospital chooses to use a color to designate patient allergies,
that it adopt the color of RED for the Allergy designation with the word “Allergy”
embossed/printed on the alert. Hospitals should develop a consistent process for
indicating specific allergy (i.e. – note all allergies in the medical record).
Do we write the allergies on the alert too?
It is recommended that allergies be written in the medical record according to your hospital’s
policy and procedure and should not be written on the alert for several reasons:
Legibility may hinder the correct interpretation of the allergy listed.
Throughout a hospitalization, allergies may be discovered by clinicians such as dieticians,
radiologists, pharmacists, etc. This information is typically added to the medical record and
not always to the alert. By having one source of information to refer to, such as the medical
record, staff of all disciplines will know where to add newly discovered allergies.
By writing allergies on the alert someone may assume the list is comprehensive. However,
space is limited on an alert and some patients have multiple allergies. The risk is that some
allergies would be inadvertently omitted—leading to confusion or missing an allergy. By
having one source of information to refer to, such as the medical record, staff of all disciplines
will know where to find a complete list of allergies.
Green – Latex Allergy
It is recommended that if a hospital chooses to use a color to designate latex as a specific
allergy, that it adopt the color of GREEN for the Latex Allergy designation with the letters
“Latex Allergy” embossed/printed on the alert.
Q. Why should we use wristbands for latex allergy alerts?
A. Many products used in hospitals are made of latex and can cause certain patients to have a
severe allergic reaction. When a patient is wearing this wristband it alerts hospital staff that
they have allergies to products containing latex and non-latex supplies should be used.
Q. Can our hospital use a red alert band to designate all types of allergies?
A. Yes. It is not mandatory for a hospital to adopt any color wristband to designate patient alerts.
Some hospitals may find a benefit in adopting a separate color for latex allergies, in which
case, we recommend green. Otherwise, a red band is sufficient with the specific type of
allergy noted in the medical record.
Yellow - Fall Risk
It is recommended that if a hospital chooses to use a color to designate falls risk that it
adopt the color of YELLOW for the Fall Risk designation with the words “Fall Risk”
embossed/written on the alert.
Q. Why did you select Yellow?
Research of other industries tells us that yellow has an association that implies “Caution!” Think of traffic lights:
yellow lights mean proceed with caution or stop altogether. The American National Standards Institute (ANSI)
has designated certain colors with very specific warnings. ANSI uses yellow to communicate “Tripping or Falling
hazards.” This fits well in healthcare when associated with a Fall Risk. Caregivers want to know to be on alert
and use caution with a person who has history of previous falls, dizziness or balance problems, fatigability, or
confusion about their current surroundings.
Q. Why even use an alert for Fall Risk?
According to the Centers for Disease Control and Prevention (CDC), falls are an area of great concern in the
aging population.
More than a third of adults age 65 years or older fall each year.
Of those who fall, 20% to 30% suffer moderate to severe injuries that reduce mobility and independence, and increase
Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes.
the risk of premature death.
Purple - DNR
It is recommended that if a hospital chooses to use a color to designate a patient’s
preferences for end-of-life care associated with DNR status that it adopt the color of
PURPLE for the Do Not Resuscitate designation with the letters “DNR” embossed/printed
on the alert.
Q. Should we use wristbands for DNR designation?
While there is much discussion regarding the issue of “to band or not to band,” a literature review to date has
not conclusively identified a better intervention in an emergency situation. One may say, “In the good old
days we just looked at the chart and didn’t band patients at all.” However, those days consisted of a workforce that was largely employed by the hospital. Today, an increasing number of healthcare providers
working in hospitals are not hospital-based staff or work for more than one facility. Travel staff may not be as
familiar with how to access information (as in the use of computerized medical records) or may not be
familiar with where to find information in the medical record. When seconds count, as in a code situation,
having a wristband on the patient is one way to improve communication and reduce the risk of an error.
Why not use Blue?
At first, blue was considered a great color choice. However, many hospitals utilize “Code Blue” to summon
the resuscitation team. By also having blue as the DNR alert color, there is the potential to create confusion.
“Does blue mean we code or do not code?” To avoid creating any second guesses in this critical moment,
we opted to not use blue.
Pink – Limb Alert/Restricted Extremity
It is recommended that if a hospital chooses to use a color to designate restricted
extremity that it adopt the color of PINK for the Limb Alert designation with the letters
“Limb Alert” embossed/printed on the alert.
Q. Why should we use wristbands for limb alerts?
A. Some patients have conditions that restrict the use of a certain arm or leg. Patients with this
condition wear a pink band on the affected extremity to alert staff to avoid using this limb for
blood draws, IV insertions, and other medical procedures.
IHA Council on Quality & Patient Safety
Hospitals that do not use color alerts should consider whether the standardized colored wrist
bands are the best solution for their hospital
Hospitals using color alerts (wristbands, stickers, etc.) are encouraged to use the Indiana
standard to improve communication
Limit additional alerts to only those needed
Use only primary and secondary colors; avoid shades of colors
Select wristbands with preprinted text
Other color alerts based on hospital choice
Do not write allergies or other patient specific information on wristbands except for patient
Engage the patient and their family in a dialog to identify risk
Request patients remove colored social cause wristbands
• Contents
Voluntary Indiana color-coded alert standards manual
Sample policy
Sample staff education brochure
Sample staff competency check list
Sample project plan
Sample patient education brochure
• Distribution
– Electronic notice sent to each hospital
• Nursing
• Quality
• Communication
– Organizational newsletters & Website
Timeline & Tracking
• Goal: 100% voluntary use of Indiana standard colors by December
31, 2009 for hospitals using color-coded wristband alerts
• Notify IHA by contacting Mikell Brown at mbrown@ihaconnect.org
when you have converted to the standardized wristband colors
In the spirit of sharing best practices for improvement, many sources contributed to the
background and materials for this implementation toolkit. The Indiana Hospital Association and
the Indiana Patient Safety Center gratefully acknowledge the following organizations and
The Pennsylvania Color of Safety Task Force, which developed the initial policy regarding
wristband color standardization.
The Arizona Hospital and Healthcare Association for their work to develop the initial
implementation toolkit.
The Wisconsin Hospital Association (WHA), whose adaptation of the toolkit was modified
for use in Indiana. Particular thanks go to Dana Richardson at WHA for granting permission
for the use of their work.
Special thanks to Jessica Langlois, Ashley Canon, Madilyn Moran, and Sarah Goranovich,
BSN students at the Purdue University Calumet School of Nursing, for providing materials
which were also adapted for this toolkit.
Direct questions to
Betsy Lee, RN, MSPH
Director, Indiana Patient Safety Center