In December 2005, a patient safety advisory was issued from the Pennsylvania Patient Safety Reporting System that received national attention. This advisory brought to surface an incident that occurred in a hospital in which clinicians nearly failed to rescue a patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as “DNR” (Do Not Resuscitate).
The source of confusion was a nurse that had incorrectly placed a yellow wristband on the patient. In that hospital a yellow wristband meant DNR. In a nearby hospital, where the nurse also worked, yellow meant “restricted extremity” which was what she wanted to alert staff about. Fortunately in this case, another nurse recognized the mistake and the patient was resuscitated.
We wanted to assess if this was a potential for harm in Oregon. In November 2006, surveys were sent to hospital QI Directors and Patient Safety Officers asking questions related to Color-coded Wristbands. The results were concerning; seven different colors/methods are being used in Oregon to convey allergy status and four colors/methods are being used to convey DNR.
This document represents our recommendations for color coding in Oregon hospitals.