Color coding is ubiquitous in hospitals. Color is a hospital messenger. Wrist bands, containers, charts, ID badges, signs, walls and floors carry directions and warnings or communicate patient wishes. No doubt, many individual systems have been shaped by ergonomic principles and deliver their messages efficiently and clearly. Nonetheless, as it stands, color-coding is potentially perilous to patients.
The problem is the sheer number of color-codes in the nation’s hospitals. The New York Times recently headlined the confusion and consequent danger of having many systems in use, recounting the oft-used cautionary story of a fatal medical effor in Pennsylvania in 2005 to illustrate the underlying problem; that colors and meanings vary from hospital to hospital. Clinicians failed to rescue a patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as Do Not Resuscitate. A nurse, who worked in two hospitals, had placed a DNR yellow band on the patient, believing yellow meant Restricted Extremity (don’t draw blood from that arm), as it did at the nurse’s other hospital.
The color yellow is the universally recognized sign for caution, but in a hospital it might mean DNR, or signal the need for special precaution or the risk of a fall. The NYT article pointed out that a survey by the Greater New York Hospital Association in 2007 found nine different colors used to denote patients with DNR orders, five to indicate allergies and nine to highlight risks of falling.
In a 2006 survey of hospitals, the Pennsylvania Patient Safety Authority found at least nine colors were used to communicate 22 medical messages, according to the Courier-Times newspaper in that state.
The NYT found that the green No Blood Transfusions code in the St. Luke-Roosevelt Hospital Center in New York, usually a request of a patient with religious beliefs that conflict with transfusions, indicates a latex allergy in Minnesota, Colorado and New Jersey.
The Case for Standardization
A nationwide movement to standardize color coding has grown in recent years. Proponents argue that standardized colors are essential to patient safety. The goal is to prevent mistakes like giving the wrong food to an allergic child, or allowing a patient with balance problems to walk unaided or serving food to a patient scheduled for surgery.
For an individual hospital, a well designed color system could be counted on to enhance the patient’s safety. The case for standardizing color-codes across wide areas lies in the fact that health care workers change jobs, and many work at more than one hospital. With every change of workplace, there is a likely change to an unfamiliar color coding system and the potential for confusion and medical error.
California, Colorado, Illinois, Kansas, Missouri, New Jersey, New Mexico, Oregon, West Virginia and Arizona are among states that are working to establish statewide standards.
Arizona is chosen to be a leader in the effort, according to the Safe and Sound patient safety program of its Hospital and Healthcare Association. "The goal is for every hospital in Arizona to have a standardized color-coded wristband system implemented by the end of this year and raise the level of patient safety in the State," said program director Barb Averyt in her organization’s publication in August 2007.
The journey to standardization could be long and pitfall-ridden: Agreement on color codes could be hard to find.
There is potential peril in relying on historic precedent, for example, and in the common sign language of colors. Yellow, for falls, is commonly understood as a symbol for caution, whether by janitors mopping floors or by traffic engineers. Red, for allergies, is associated with a command to stop and check for danger. In the past, some hospitals have used blue to signify DNR, but it was ruled out on a national level, according to the NYT article, because the phrase Code Blue is often used to call for resuscitation—the opposite of what DNR patients want.
The article notes that a system has been introduced at the city’s 11 public hospitals to designate patient conditions. Purple means DNR. Red indicates allergies, while yellow signifies someone at risk for falling.
Ohio has adopted the red and yellow bands but has avoided the purple ones because they conflict with a state law requiring a transparent wristband for DNRs.
At Metropolitan Hospital in New York, officials handed out red, yellow and purple pens to drive home the new color-coding system to the staff. The hospital had previously used red bands, now for allergies, to denote No Blood Transfusions, now green.
Another New York hospital, St.Luke’s-Roosevelt, began using the yellow and red bracelets in September, but is still debating whether to add purple. In Arizona, one hospital embossed its purple bracelets with a white dove carrying an olive branch, rather than DNR, while another chose the initials AND, for Allow Natural Death, as a gentler alternative.
Kim Miyauchi, associate nursing director at Kingman Regional Medical Center, the Arizona hospital that uses the white dove, said officials there worried that wearing the initials DNR on one’s wrist was “a little bit harsh,” and also failed to convey nuances best captured in a medical chart, as with a patient who wants medication for heart failure but not to be shocked by a defibrillator.
An Associated Press article in December noted that the Louisiana Hospital Association urges a statewide color code for wristbands to alert staff to a patient’s wishes and risks. The colors announced were: Purple for patients who don’t want resuscitation; yellow for those likely to fall; red for allergies; green for latex allergies and pink when an arm should be avoided for intravenous lines or drawing blood.
The American Hospital Association urged states in September to use the red, yellow and purple codes. Its Web site indicates that about 25 states do, and at least four have added the same green and pink codes as Louisiana.
Purple bands, typically embossed with the letters DNR to reinforce the message, are meeting with some resistance.
Patient Privacy and Sensitivity
The nation’s leading hospital-accreditation agency, known as the Joint Commission, cites concerns about branding patients by their end-of-life choices, or inadvertently broadcasting those choices to family and friends who have not been consulted.
The commission also said that children who do not understand the system had been prone to trade the wristbands like baseball cards.
Roxanne G. Tena-Nelson, executive vice president of the Continuing Care Leadership Coalition, a group of long-term-care providers in New York, explained in the NYT article that balance is needed between patient safety and accuracy, patient privacy and sensitivity and compassion for the patient. “Sometimes people want varying levels of treatment at the end of life,” she said. “Sometimes it’s not so clean as just don’t do anything.”
A simple system that recognize peripheral concerns, like patient privacy, represents a useful goal. Efforts to reach the same goal statewide, then nationwide, represent a better goal: It could relegate accidents and near-accidents, like the Pennsylvania patient’s yellow DNR wristband, to medical history books. The Courier-Times notes that Pennsylvania hospital officials, aware of the range of potential perils associated with color coding, advise using it sparingly and in conjunction with other safeguards. These include repeatedly questioning patients or making notations on charts, to communicate important patient health information.
Sources: New York Times; Hospital and Healthcare Association; Courier-Times; Associated Press; American Hospital Association
This article originally appeared in The Ergonomics Report™ on 2008-12-10.