Projects
MPSC has worked on a variety of patient
safety initiatives:
The MPSC also participated in the
Wisconsin Hospital Association initiative for standardizing wristband
colors.
Patient safety is a top priority for Wisconsin health
care organizations. Hospitals advance safety initiatives in many ways.
The newest initiative in Wisconsin is a statewide commitment to
standardize the colors used to identify patients and medical alerts.
Many Wisconsin hospitals use
color-coded alerts as a way of quickly identifying important information
about patients. Wristbands, stickers and
placards
are commonly used to identify allergy warnings, fall risks, or
do-not-resuscitate (DNR) orders. However, until now, there has not been
a standard that offers direction to hospitals as to what color
identifies which alert. Many health professionals work in multiple
facilities so they must memorize multiple, sometimes conflicting,
color-coded alert systems.
The issue of alert colors was first raised by
the Pennsylvania Patient Safety Authority after an event in which a
clinician nearly failed to rescue a patient due to an incorrect “DNR”
designation. The source of confusion started when a nurse had placed a
yellow alert on the patient. In this hospital, the color yellow
signified that the patient was a DNR. In a nearby hospital, where 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, the mistake was identified and the patient was
resuscitated.
Similar incidents have occurred in Wisconsin hospitals.
For example, Dennis, a young man experiencing serious heart problems,
was transported from Upland Hills Health in Dodgeville to a Madison
hospital for advanced heart care. Upon arrival at the Madison hospital,
a nurse commented on his “DNR” wristband. Dennis and his wife were
horrified to learn that the patient name band placed on his wrist at
Upland Hills Health in Dodgeville was the same blue color as the Madison
hospital’s DNR wristband. Luckily, this misinterpretation was
immediately clarified and the wristband was removed before any
life-sustaining care was withheld. These “near misses” highlight a
potential source of error and an opportunity to improve patient safety
by re-evaluating the use of color-coded alerts.
Fourteen states
have chosen to standardize color codes, eight others are considering
it. While there is not an official national standard, a majority of
states that have standardized have chosen the same colors, including
states bordering Wisconsin. Wisconsin is in the process of implementing
these same color standards to ensure that patients and heath care
employees will have consistent standards when they work across state
line. The colors are:
White or Clear
for Patient Identification
Purple for DNR
Red for Allergy
Yellow for Fall Risk
Facilities that
are not currently using color-coded alerts are not encouraged to start.
While this is a
voluntary program, the Wisconsin Hospital Association’s goal is for 100
percent of hospitals to make the transition to the standard colors by
March 1, 2009.
If you have any
questions about this project, please contact Dana Richardson at
drichardson@wha.org or 608-268-1824.
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