Standardization of Color-Coded Alerts: Time for a National Effort

By Fabiola Lalande, RN, BSN

In 2005, the Pennsylvania Patient Safety Reporting System received a report of a near miss that brought up a new issue in the nursing field. It involved a nurse who worked in two hospital facilities; one facility used yellow wristbands for limb restrictions (do not use this limb) and the other facility used them to indicate DNR (do not resuscitate). This nurse had a patient with arm restrictions. So, well-intentioned, she placed a yellow wristband on the patient’s arm. At that point, she hadn’t realized that yellow meant DNR in that hospital. Unfortunately, the patient ended up having a cardiopulmonary arrest and the nurse who witnessed the event failed to start rescue CPR. She had noticed that the patient was wearing a yellow wristband and concluded that the patient had a DNR code status. Luckily, the mistake was caught early enough to still save this patient’s life. In this case, both nurses meant well; they both wanted to keep the patient safe and respected. In fact, the hospitals’ process was the danger.

Based on this incident, hospitals all over Pennsylvania started a movement to standardize their color-coded wristbands. Pennsylvania is the only state where the reporting of a near miss that did not harm the patient is mandated (Clarke, Johnston, & Finley, 2007; Cizek, Estrada, Allen, & Elsholz, 2010), but several similar cases where wristbands were a source of confusion have been reported (Woods & Bagian, 2011). In 2008, the American Hospital Association endorsed the national standardization of color-coded wristbands (American Hospital Association [AHA], 2008) and, although adopting a standardized color-coding system for clinical alerts may sound like a logical thing to do, so far nine states still have not taken a position on this issue: Montana, Wyoming, North Dakota, South Dakota, Georgia, Connecticut, Massachusetts, Vermont and Maine (The St. John Companies, 2011).

Some characteristics of our current healthcare system make this issue an even bigger concern. In the states where color-coded wristbands are not standardized, hospitals use a vast variation of colors to transmit the same alert. When we consider that, in addition to the fact that nurses are commonly employed in more than one facility at the same time, healthcare employee turnover is considerable, and travel nursing is becoming a popular way to supply demand, it is easy to see how we are creating a recipe for disaster. Hospitals are breeding dangerous confusion that could possibly cost our patients’ lives.

In the Journal of Patient Safety, James (2013) reports that preventable medical errors kill at least 210,000 patients a year. The study counted only fatal events; therefore the number is only a fraction of all medical errors if we take all harm and near misses into account. Medical errors are the third leading cause of death in the United States (Centers for Disease Control and Prevention, 2011). When our patients walk into hospitals, they expect to meet professionals who will help them get back on their feet, not endanger their lives. Preventable medical errors must be prevented. If a process can jeopardize someone’s life, then it must be reviewed and changed.   

An Example from Aviation

In March1977, the aviation industry took time to review its operational processes after a fatal, preventable error took 582 lives. A mistake was made by a well-regarded chief pilot who started to takeoff without getting the control tower’s clearance first. In fact, other crew members noticed the mistake, but they strongly believed that their well-qualified chief pilot would never go without having first received clearance, so they did not say anything (Nance, 2005). The end of that story was an unimaginable disaster. The airplane crashed into another airplane that was waiting to take off. This was a preventable accident that initiated a major revolution in the aviation industry. After the incident, they analyzed their processes, identified areas of potential mistakes, and decided to change them. Among those changes was implementation of a strict standardization of procedures and machinery.

Unfortunately, we all know that humans tend to make a lot of mistakes. Denham (2008), the author of May I have the envelope please?, states that “in the United States, the final key to achieving years of accident-free airline flights turned out to be nothing more than formal acceptance of the fact that people have as many performance limitations as the airplanes they fly” (p. 119). Obviously, we can’t take the aviation industry’s example and literally apply it to healthcare. However, we can learn from its willingness to change and to become the safest method of transportation.

Color-Coded Society

Most of the healthcare facilities throughout the country use some variation of color-coded wristbands to convey alerts that must be recognized at a quick glance. This is helpful when everyone can correctly identify them. We live in a color-coded society. We use red to symbolize fire, pink ribbons for breast cancer awareness, a red and white flag on a boat to warn of submerged divers, a yellow armband for Livestrong, and many others. The most common color-code used in our society is our traffic light system. The idea behind color-coding is great, but if used incorrectly, it can be very dangerous. Imagine if the three colors used in the traffic light system meant different things in each state. Driving across state lines would be a tremendously dangerous activity! People would be constantly committing traffic violations or worse, causing severe accidents. This is exactly what is happening in our hospitals. To decrease confusion, all hospitals, in all states, must use the same colors to convey the same warnings, which would significantly improve patient safety.

Wristband color standardization may not be the main issue in healthcare today, but it is an easy one to fix. Interestingly, it is also one that is not well accepted by hospital facilities that insist on continuing to use color coding the way they always have. Wachter (2008) reflects that in a standardized process “people will speak in the same language with standard terms and that creates a huge amount of predictability and safety, something you don’t see in hospitals” (p. 147).

The American Hospital Association’s recommended colors are red to indicate an allergy, yellow for falls risk, and purple for do not resuscitate (AHA, 2008). There are also other standardized color-coded alerts for limb restriction (pink) and latex allergy (green) (The St. John Companies, 2011). Hospitals have the choice to decide what alerts they want to use, but the warnings must be the same. Some states opted out of latex allergy, choosing to include it with the red allergy wristband. Others opted not to have a limb restriction wristband, but overall, the wristbands they do use are uniformly sending the same message. This is a crucial aspect of nursing care; avoiding confusion by sending clear messages is essential to prevent patients’ harm or even death.

Standardized color-coding is a movement that needs to continue throughout the country. Sehgal and Wachter (2007) recommend a national mandate on the standardization of DNR status, affirming that it would reduce medical errors and increase adherence to patients’ wishes. Standardization of processes to prevent errors is not a new subject. The Joint Commission issued a Sentinel Event Alert in 2001 about problematic abbreviations and in 2004 created a list of “do not use” abbreviations to reduce confusion (Joint Commission, 2013). Standardization of color-coded wristbands is a simple process to put in place. Staff nurses can lead this movement in their own hospitals by bringing the topic to their nurse leaders and discussing the ways in which this process can dramatically improve patient safety. Nurses are the driving force behind standardization of color-coded wristbands. States’ hospital associations, nursing organizations, administrative leaders, and medical associations should all support this movement. Perhaps an endorsement from the Department of Public Health and The Joint Commission would gain the attention of all the stakeholders. It is a simple way to benefit nurses and patient outcomes with minimal cost. The standardization of color-coded alert wristbands is vital in our current economy and healthcare system.

Fabiola Lalande has held nursing positions on critical care, telemetry, and medical-surgical hospital units. She has also served as RN preceptor and DEU program clinical teacher for Regis College in Weston, Massachusetts. Lalande has a special interest in nursing quality and education. She is currently a graduate student at Regis College and may be contacted at


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