Background: Color-coded Wristband Standardization Project in Texas

1. Background: Color-coded Wristband Standardization Project in Texas • In 2005, Pennsylvania had a “near miss” when there was confusion regarding wristband color that resulted in a patient being labeled DNR erroneously. • Following the incident in Pennsylvania, states started standardizing wristband colors. • As of fall 2008, more than 25 states standardized wristband colors: • Do-Not-Resuscitate - Purple • Allergy - Red • Fall Risk - Yellow

2. Confusion regarding wristband color resulted in a patient being labeled DNR erroneously. Was there a potential for harm in Texas? In January 2008, surveys were sent to members of the Texas Organization of Nurse Executives asking questions related to color-coded wristbands. The results were concerning. Six solid colors were used to designate 32 conditions.

3. 2008 Texas Hospital Nurse Staffing SurveyTexas Center for Nursing Workforce Study • Texas hospitals reported an average of 11.2 percent nursing positions as vacant. • The same survey reports the hospital turnover rate for RNs as 16.1 percent. • More than 56.4 percent of hospitals reported using temporary staffing agencies or contract traveling RNs to replace sick or absent nurses.

4. Insanity: doing the same thing over and over again and expecting different results. ~ A. Einstein The Texas Initiative Under the direction of the Texas Hospital Association, TMF Health Quality Institute, Texas A&M Health Science Center Rural and Community Health Institute and the Texas Organization of Nurse Executives, a workgroup was convened to address the standardization of color-coded wristbands in Texas. Standardize three condition alerts: • Do-Not-Resuscitate • Allergy • Fall Risk

5. The Texas Initiative – Partner Deliverables • Standardize color-coded wristbands statewide • Reach consensus on color definitions • Develop a toolkit for all hospitals

6. Implementation Materials • Executive Summary and Background • Standardized Wristband Colors • Work Plan for Implementation • Staff and Patient Education/Materials • Policy and Procedure

7. Standardized Wristband Colors

8. Recommendation: DNR - Purple Texas hospitals are encouraged to adopt the color PURPLE for the do-not-resuscitate designation with the letters “DNR” reversed out in white on the wristband.

9. Recommendation: Allergy - Red Texas hospitals are encouraged to adopt the color RED for the allergy alert designation with the words “ALLERGY” embossed/printed on the wristband. By adopting red for allergy, the standardization for this is easily achieved since most Texas hospitals already use red for allergy alert

10. Recommendation: Fall Risk - Yellow Texas hospitals are encouraged to adopt the color YELLOW for the fall risk alert designation with the words “FALL RISK” embossed/printed on the wristband. Falls account for more than 70 percent of the total injury-related health care costs among people 60 years of age and older.

11. Work Plan – How to Implement

12. Work Plan – How to Implement A suggested work plan for facility preparation, staff education and patient education includes: • Organizational Approval • Supplies Assessment and Purchase • Hospital-specific Documentation • Staff and Patient Education and Training Following the work plan is a task chart for each activity that provides cues for methodical and successful implementation.

13. Sample Work Plan Document

14. Sample Task Chart

15. Staff and Patient Education

16. Tools for Staff Education • PowerPoint® presentation • Poster announcing training meeting session dates/times • Staff sign-in sheet • Tri-fold staff education brochure about this initiative • Frequently Asked Questions • Staff competency checklist • Tri-fold patient education brochure about color-coded wristbands • Sample news release

17. Tri-fold Staff Education Brochure • How this all got started…the Pennsylvania story • Why we need to do this in Texas • The colors for allergy, fall risk and DNR • Model script to deliver consistent information to patients about the standardized color-coded wristbands program • “Quick Reference Card” that lists 7 risk-reduction strategies 

18. Risk-Reduction Strategies Color-Coded “Alert” Wristbands / Risk-Reduction Strategies – A Quick Reference Card =============================================================== • Use wristbands with the alert message pre-printed (such as “DNR”). • Remove any “social cause” colored wristbands (such as “LIVESTRONG”). • Remove wristbands that have been applied by another facility, except for emergency identification bands.

19. Risk Reduction Strategies Color-Coded “Alert” Wristbands / Risk-Reduction Strategies -- A Quick Reference Card ================================================================ • Initiate banding upon admission, changes in condition or receipt of information during the hospital stay. • Educate patients and family members regarding the wristbands. • Coordinate chart/white board/care plan/door signage information/stickers with same color coding. • Educate staff to verify patient color-coded “alert” wristbands upon assessment and during hand-off of care and facility transfer communication.

20. Why have a script for staff? • How something is said is just as important as what is said. The toolkit provides a “script” so staff can work on the “how” as well as the “what.” • Serves as an aid to help staff be comfortable when discussing the topic of a DNR wristband. • Promotes patient/family involvement and reminds the patient/family to alert staff if information is not correct. • By following a script, patients and families receive a consistent message – which helps with retention of the information. • A patient education brochure also is available for staff to distribute.

21. Script for staff • What is a color-coded “alert” wristband? Color-coded alert wristbands are used in hospitals to quickly communicate a certain health care status or condition that a patient may have. The color-coded wristband is a visual “alert” for all staff members and helps every staff member. • What do the colors mean? This hospital uses three different color-coded “alert” wristbands, and they are the ones most commonly used in Texas as well as in hospitals in multiple other states.

22. Script for staff • Red means allergy alert Patients should inform caregivers about an allergy to anything – food, medicine, latex, dust, grass, pet hair, etc. The red wristband reminds caregivers to check the allergy before delivering food, medicine or other aspects of care. This can be very important to avoid unpleasant reactions. • Yellow means fall risk The hospital wants to prevent falls at all times. Nurses continuously assess patients to determine if they need extra attention to prevent a fall. Sometimes, a person may become weakened due to the illness or because of a recent surgery. When a patient has this color-coded alert wristband, the nurse is indicating that the patient needs to be assisted when walking to avoid a possible fall.

23. Script for staff • Purple means the physician has written a do-not- resuscitate order. When patients have expressed an end-of-life wish, the hospital and its caregivers want to honor it.

24. Policy and Procedure

25. Hospital Policy and Procedure • A model policy and procedure is provided. • Modify as necessary so it fits your organization’s process and culture. • A “Patient Refusal to Cooperate with Color-Coded Wristband Standardization Project” form is included.

26. Excerpt from Refusal Form The above named patient refuses to: (check what applies) □ Wear color coded alert wristbands. The benefits of the use of color-coded wristbands have been explained to me by a member of the health care team. I understand the risk and benefits of the use of color-coded wristbands, and despite this information, I do not give permission for the use of color-coded wristbands in my care. □ Remove “social cause” colored wristbands (like “LIVESTRONG” and others). The risks of refusing to remove the “social cause” colored wristband have been explained to me by a member of the health care team. I understand that refusing to remove the “social cause” wristbands could cause confusion in my care, and despite this information, I do not give permission for the removal of the “social cause” colored wristband. Reason provided (if any): __________________________________________________ ________________________________________________ Date / Time Signature / Relationship _____________ ________________________________________________ Date / Time Witness Signature / Job Title

27. Resources

28. Resources • To access an online version of this toolkit, go to the Texas Hospital Association Web site at: www.texashospitalsonline.org/wristband • To access the Pennsylvania Patient Safety Advisory report: http://www.psa.state.pa.us/psa/lib/psa/advisories/v2_s2_sup__advisory_dec_14_2005.pdf • Questions? [Add facility-specific contact information here]

29. Color-coded WristbandStandardization Project in Texas Our safety as a state and success in this effort will depend on the participation of and adoption by each and every hospital in this state as soon as feasible.