Color-Coded Alert System Standardization in Virginia. Patient safety is sound clinical practice

Transcription

1 Color-Coded Alert System Standardization in Virginia Patient safety is sound clinical practice

2 Table of Contents Executive Summary Background / Virginia Survey... 3 Recommendations for Adoption The Colors... 4 Risk Reduction Strategies... 6 Work Plan How to Implement Work Plan Guide... 7 Task Charts... 8 Staff & Patient Educational Materials Staff Education Training Tips The Tools Posters, Staff Training Meeting Announcement Sign-In Sheet, Staff Training Material Staff Education Brochure FAQs Competency Checklist, Staff Patient Education Brochures, English and Spanish Policy and Procedure Sample Policy & Procedure Patient Refusal Form Vendor Information Task Force Acknowledgements Color-Coded Alert System Standardization in Virginia

3 In December 2005, the Pennsylvania Patient Safety Reporting System issued a patient safety advisory that received national attention. This advisory detailed an incident in which clinicians nearly failed to rescue a hospital patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as DNR (Do Not Resuscitate). A nurse had incorrectly placed a yellow wristband on the patient, which designated DNR in that hospital. The nurse also worked in a nearby hospital, where yellow meant restricted extremity. Fortunately in this case, another nurse recognized the mistake, and the patient was resuscitated. We wanted to assess potential for similar harm in Virginia. In September 2008, surveys were sent to Virginia hospitals and nursing homes asking questions related to color-coded wristbands. Different methods/colors are being used throughout Virginia for alert notifications: N=225 Notification methods of Virginia hospitals and nursing homes: (Note: respondents were able to choose multiple notification methods) 53% use wristbands 2.4% use barcoding technology 50% use patient chart only 25.5% use signage around bed or in patient area 39.2% use sign on door to patient room 30.2% use other methods 94% do not use purple for DNR 52% do not use red for Allergy 83% do not use yellow for Fall Risk The trend to standardize wristbands has swept the nation with 40 states having implemented or in the process of standardization. At the direction of the VHHA Board of Directors, a task force was convened to address the standardization of color-coded wristbands in Virginia. Given the problems that may occur between transfer of patients from a long-term care facility with its own color-coded alert system policy to a hospital that uses different colors and vice versa, it was apparent that nursing homes must be included in the implementation plan for standardization to succeed in Virginia. Patient safety is sound clinical practice Executive Summary The task force focused on three condition alerts: 1. Do Not Resuscitate 2. Allergy 3. Fall Risk The composition of the team and ad hoc members included hospital and nursing home risk managers, nurse managers/ coordinators, quality/safety/performance improvement officers and executive leadership. The task forces objectives were to: 1. Reach consensus on color definitions. 2. Develop a work-plan and create an Implementation Toolkit for hospitals and nursing homes to use to adopt the standardization. 3. Standardize color-coded alert systems statewide. This toolkit is designed to assist facilities in color-coded wristband standardization. The information that follows in this kit will guide your organization through: 1. The colors for the alert designation and logic for the colors selected 2. Work plan for implementation 3. Staff education including competencies 4. FAQs for general distribution 5. Sample policy and procedures 6. Vendor information for easy adoption of the recommendation 7. Patient education brochure Our success in this effort will depend on the participation and adoption by all Virginia hospitals and nursing homes not using advanced warning methods (e.g., bedside barcoding). This effort will require a willingness to change for the greater good. Some institutions will have a minor change while others may require a major changes. We realize that change is difficult; we also realize that change made for reasons that benefit the safety of your staff, your loved ones and your communities are changes for all the right reasons.

4 Recommendations for Adoption Do Not Resuscitate = Purple Allergy = Red Fall Risk = Yellow Do Not Resuscitate Recommendation: It is recommended that the color PURPLE be adopted for the Do Not Resuscitate designation with the letters DNR embossed/printed on the wristband. While there is much discussion regarding the issue of to band or not to band, a literature review to date has not identified conclusively a better intervention. One may say, In the good old days, we just looked at the chart and didn t band patients at all. However, those days consisted of a workforce base that was largely employed by the hospital/nursing home, current processes must reflect the fact that an increasing number of health care providers working in hospitals or nursing homes are not facility employees. Registry and traveler staff may not be familiar with how to access information (as in the use of computerized charts), may not be familiar with where to find information in the medical record or even where to find the medical record. When seconds count, as in a code situation, having an alert wristband on the patient will serve as a great tool. Similar to a second identifier, it will serve as a ready communication in crisis, evacuation or in transit situations. We do not use wristbands for DNRs at our facility. Q Why should we consider adopting this? Wristbands are used to communicate an alert. A Registry staff, travelers, non-clinical staff, etc., may be unaware of where to look in the medical record if they are new to your institution. By banding a patient, a quick warning is communicated so everyone knows about this alert. Additionally, it also is a means to communicate to the family that we are clear about their end-of-life wishes. By not having a band on, errors of omission may be created. So, if we adopt the purple DNR wristband then do Q we still need to look in the chart? Yes. Some facilities do not use wristbands for DNRs A because they want the chart to be reviewed first for the most current code designation. However, that practice should be the practice in all cases whether a wristband is being used or not. Code status can change throughout a stay. It is important to know the current status so patients and families wishes can be honored. Allergy Recommendation: It is recommended that the color RED be adopted for the Allergy Alert designation with the word Allergy embossed/printed on the wristband. Q Do we write the allergies on the wristband, too? It is our recommendation that allergies be written in A the medical record according to your facility s policy and procedures. We suggest allergies not be written on the wristband for several reasons: 1. Legibility may hinder the correct interpretation of the allergy listed; 2. By writing allergies on the wristband, someone may assume the list is comprehensive. However, space is limited on a wristband and some patients have 12 or more allergies. The risk is that some allergies would be inadvertently omitted, leading to confusion or missing an allergy; 3. Throughout a stay, allergies may be discovered by other caregivers, such as dietitians, radiologists, pharmacists, etc. This information is typically added to the medical record and not always to a wristband. By having one source of information to refer to, such as the medical record, staff of all disciplines will know where to add newly discovered allergies. Color-Coded Alert System Standardization in Virginia

5 Recommendations for Adoption (continued) Fall Risk Recommendation: It is recommended that the color YELLOW be adopted for the Fall Risk Alert designation with the words Fall Risk embossed/written on the wristband. Q Why even use an alert band for Fall Risk? According to the Centers for Disease Control and A Prevention (CDC), falls are of great concern in the aging population: 1. More than a third of adults aged 65 years or older fall each year. 2. Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes. 3. Of those who fall, 20% to 30% suffer moderate to severe injuries that reduce mobility and independence and increase the risk of premature death. 4. In 2000, the total direct cost of all fall injuries for people 65 and older exceeded $19 billion. The financial toll for older adult falls is expected to increase as the population ages, and may reach $54.9 billion by 2020 (adjusted to 2007 dollars). 5. In 2004, there were more than 320,000 hospital admissions for hip fractures, a 3% increase from the previous year. However, from 1996 to 2004, after adjusting for the increasing age of the U.S. population, the hip fracture rate decreased 25% (from 1,060 per 100,000 population to 850 per 100,000 population). Over 90% of hip fractures are caused by falling, most often by falling sideways onto the hip. In 1990, researchers estimated that the number of hip fractures would exceed 500,000 by the year As the aging population enters a health care facility, one must consider the risk that is present and communicate that risk to staff. For more information about falls and related statistics, go to fallcost.htm. Patient safety is sound clinical practice

6 Risk Reduction Strategies Color-Coded Alert Wristbands / Risk Reduction Strategies Quick Reference Card 1. Use wristbands with the alert message pre-printed (such as DNR ). 2. Remove any social cause colored wristbands (such as Live Strong ). 3. Remove wristbands that have been applied from another facility. 4. Initiate banding upon admission, changes in condition or when information is received. 5. Educate patients and family members regarding the wristbands. 6. Coordinate chart/white board/care plan/door signage information/stickers, etc., with same color-coding. 7. Educate staff to verify patient color-coded alert wristbands upon assessment, hand-off of care and facility transfer communication. Add brochure to employee orientation packet. 1. Use wristbands that are pre-printed with text that tells what the band means. a. This reinforces the color-coding system for new clinicians, helps caregivers interpret the meaning of the band in dim light and also helps those who may be color blind. b. This eliminates the chance of confusing colors with alert messages. 2. Remove any social cause (such as Live Strong, Cancer, etc.) colored wristbands. a. Address this in your facility s policy. b. If that can t be done, you can cover the band with a bandage or medical tape, but removal altogether is best. 3. Remove wristbands that have been applied from another facility. a. This should be done during the entrance to facility and/or admission. b. Address this in your facility s policy. 4. Initiate banding upon admission, changes in condition or when information is received. 5. Educate patients and family members regarding purpose and meaning of the wristbands. a. Include the family in this as a safeguard for you and the patient. b. Remind them that color-coding provides another opportunity to prevent errors. c. Use the Patient/Family Education brochure located in this toolkit. 6. Coordinate chart/white board/care plan/door signage information/stickers, etc., with same colorcoding, for allergies, fall prevention and DNR status. 7. Educate staff to verify patient color-coded alert wristbands upon assessment, hand-off of care and facility transfer communication. 8. When possible, limit the use of colored arm bands, for other categories of care (e.g., latex, MRSA, tape). 9. Remember, the wristband is a tool to communicate an alert status. a. Educate staff to utilize the patient s medical record information (e.g., physician order for DNR) for verification process for allergies, fall risk and advance directives. 10. If your facility uses pediatric wristbands that correspond to the Broselow color-coding system for pediatric resuscitation, take steps to reduce any confusion between these Broselow colors and the colors on the wristbands used elsewhere in the facility. Color-Coded Alert System Standardization in Virginia

7 Area #1 Organizational Approval & Awareness (See Task Chart for specific steps) Review Adopting this initiative may need approval by appropriate committees, such as: Patient Safety Committee Medical Staff Committee Quality Improvement Council Board of Directors Action Plan Organizations have different committees that need to approve system-wide changes or changes that directly affect patient care. Each organization must identify committees that must approve the adoption of the initiative and begin to get on meeting agendas. For some organizations this may mean giving a presentation at one committee; other organizations will require approval by several committees. Consider the stakeholders and be sure they approve and understand the initiative before it is implemented so they can support it. Area #2 Supplies Assessment and Purchase (See Task Chart for specific steps) Review Assessment of current supply Wristband procurement Action Plan Most organizations have a vendor they are using for wristbands, and VHHA has partnered with Precision Dynamics to supply wristbands too. Whichever vendor you choose, it is important to communicate to them that you are adopting the Virginia model for colorcoded wristbands. If your vendor does not know about the Virginia standardization, inform them of the colors and the alert message that needs to be printed directly on the band (please see Vendor Information section). They will need some lead time for the imprinting. Coordinate with your Materials Management department to evaluate when current stock will be used up. Once this is known, the rest of the implementation plan will back fill into this date. Patient safety is sound clinical practice Work Plan How to Implement Suggested Work Plan for facility preparation, staff education and patient education Area #3 Facility Specific Documentation Review Policy adoption Long Term Care Admissions Packet Assessment Revision Forms revised to meet standards Consents Action Plan Color-banding policy should be reviewed and approved if changes are made. Facilities should review their respective forms for possible modifications (patient education assessments, etc.). You may want to include indicators that the patient received the wristband education brochure. (See Patient Education section.) Discuss policies and procedures to be followed if a patient refuses to wear a wristband. A sample document indicating such refusal is provided in this Toolkit. Coordinate with risk management staff and individual administrators. Area #4 Staff and Patient Orientation, Education and Training Review Schedule/training content Documentation requirement Posters & FAQs Action Plan Review education format and training materials. Standardize competency content and format. The competency form may be individualized by the facility. Schedule, complete and document staff education per facility policy. Make changes to the New Employee Orientation so that current information is provided. Coordinate with individual hospital and nursing home education staff.

8 Suggested Task Chart for Facility Preparation STEP 1 Area #1 Organizational Approval & Awareness When: WEEK ONE enter date this is done: Get contact information for each staff person who supports meetings of the following committees: Patient Safety Committee Medical Staff Committee Nursing Practice Council Quality Improvement Council Board of Directors Other? NOTE: Not all committees will need to approve this initiative. However, they will usually benefit from a presentation that provides the information about this initiative so they can support it. With help from administrative team, identify committees that should receive presentations. Notes / Comments / Follow-ups Committee Name /ext. Patient Safety Committee Medical Staff Committee Nursing Practice Council Quality Improvement Council Board of Directors Other Other Other STEP 2 When: WEEK ONE Find out when the next meetings are and get on agenda to convey information on the initiative and, if needed, acquire approval. NOTE: Not all committees will need to approve this initiative. However, relevant committees will benefit from a presentation that provides the information about this initiative so they can support it, so these presentations should be considered a priority as well. Notes / Comments / Follow-ups Committee Name /ext. Patient Safety Committee Medical Staff Committee Nursing Practice Council Quality Improvement Council Board of Directors Other Other Other Color-Coded Alert System Standardization in Virginia

9 Suggested Task Chart for Facility Preparation STEP 3 Area #1 Organizational Approval & Awareness When: Pending Committee Approvals After presentations are made and approval is obtained to adopt recommendations, contact pertinent department/staff to move forward. Convey info (see right column) Notes / Comments / Follow-ups Department Info to be Conveyed Follow-ups Materials Management 1. Approvals obtained. How long until delivery?. Order wristbands.. When will bands be available? Take that date and add 5-7 more days that is your Go Live date. (The 5-7 days are added to allow for distribution of wristbands to pertinent areas.) Staff Education 1. Wristbands will be arriving in about weeks.. Go Live date is weeks.. Start education. Risk Management and/or QI Director 1. Wristbands will be arriving in about weeks.. Go Live date is weeks. 3. Confirm policy & procedure has been approved, and prepare to add to P&P manual. Other Departments 1. Wristbands will be arriving in about to consider: weeks. Medical Staff, Admitting, 2. Go Live Date is weeks. ED, Peri-Op, Nursing, Lab, 3. Start education. Coordinate with Education Dietary, Laboratory, department for either materials, training Radiology, Pharmacy, etc. or information. Patient safety is sound clinical practice

10 Suggested Task Chart for Facility Preparation Area #1 Organizational Approval & Awareness STEP 4 If any other steps required, add them here. Notes / Comments / Follow-ups STEP 5 If any other steps required, add them here. Notes / Comments / Follow-ups STEP 6 If any other steps required, add them here. Notes / Comments / Follow-ups 10 Color-Coded Alert System Standardization in Virginia

11 Suggested Task Chart for Facility Preparation Area #2 Supplies Assessment and Purchase STEP 1 When: WEEK ONE enter date this is done: Contact Materials Manager and brief on the initiative. Answer questions and share the Toolkit. Remember: You are just gathering information. Do not order wristbands until organizational approval has been obtained. Other Notes / Cues Coordinated with Materials Management (MM) person who will do the ordering. MM Name: Phone: STEP 2 When: WEEK ONE Ask Materials Manager when current supply of wristbands will run out. This is based on estimates from typical order patterns and staff usage. Other Notes / Cues Allergy Bands run out about (ex: mid-march 09) Fall Bands run out about DNR Bands run out about STEP 3 When: WEEK ONE Ask Materials Manager to contact wristband vendor and alert them to change in supply color. Convey info to the right. Check off items once communicated to vendor. Other Notes / Cues ALLERGY BAND: o Red: PMS 1788 o ALLERGY pre-printed on band in black 48 pt. Arial Bold, all caps FALL BAND o Yellow: PMS 102 o FALL RISK pre-printed on band in black 48 pt. Arial Bold, all caps DNR BAND: o Purple: PMS 254 o DNR pre-printed on band in white 48 pt. Arial Bold, all caps STEP 4 When: WEEK TWO Follow-up with Materials Management in a week and validate that they were able to contact vendor. Complete info in right column from Materials Management. Other Notes / Cues Lead time required when ordering wristbands is: ALLERGY BAND: FALL BAND: DNR BAND: Patient safety is sound clinical practice 11 weeks weeks weeks

12 Suggested Task Chart for Facility Preparation Area #2 Supplies Assessment and Purchase STEP 5 When to Do It Other Notes / Cues Assure Materials Management staff that you will contact them to order wristbands once organizational approval has been obtained and Policy and Procedure changes have been approved. Give status report to Materials Management within a month of initial contact to keep them apprised of progress. STEP 6 If any other steps required, add them here. When to Do It Other Notes / Cues STEP 7 If any other steps required, add them here. When to Do It Other Notes / Cues STEP 8 If any other steps required, add them here. When to Do It Other Notes / Cues 12 Color-Coded Alert System Standardization in Virginia

13 Suggested Task Chart for Facility Preparation STEP 1 Area #3 Facility Specific Documentation When: WEEK TWO or THREE enter date this is done: Contact chief nursing officer and clinical directors to review if documentation process addresses wristbands specifically. (e.g., daily nursing charting) Remember: This is not a recommendation to add wristbands to your documentation process or color specific information, but to review your current documents policies and processes. Other Notes / Cues Coordinate with CNO and Clinical Directors It may be helpful or more efficient for you to pull the daily documentation information for the various areas and review the current requirement. Consider these documents: ED Triage record or Treatment/ED Nurses Notes Admitting Assessment ICU Nurses Notes Peri-Op Assessments/Notes Daily Nursing Documentation Other: STEP 2 When: WEEK TWO or THREE If your current documentation process addresses wristbands, review documents to assure any reference to colors are updated to reflect these changes. Other Notes / Cues Again, this is not a recommendation that the documentation reflect color information about wristbands. However, if your documentation is color specific, this is a cue to validate that the information be updated to reflect the new colors if that is your current process. STEP 3 When: WEEK THREE or FOUR If changes are required to the documentation forms, contact Forms Committee and pertinent clinical directors to initiate process for changes. Other Notes / Cues Some facilities require that any changes to forms be reviewed through a Forms Committee or similar entity. Other facilities do not require this process if changes are minimal or they do not change content. This step is to determine your facility s process. STEP 4 When: WEEK THREE or FOUR Once process is known, and if a form(s) update is required, factor the print time and new form availability into the timeline so the education and implementation processes are in sync with the arrival of new documents. Other Notes / Cues Patient safety is sound clinical practice 13

14 Suggested Task Chart for Facility Preparation Area #3 Facility Specific Documentation STEP 5 When: WEEK FOUR Review and update the Policy and Procedure for wristband application to reflect the new process. Obtain a copy of the current wristband P&P and review content. Other Notes / Cues A sample P&P has been provided for you to use as a template. Review this sample and adapt its content to work in your facility. NOTE: It is important that you compare your current process with the sample P&P and determine what elements you will change. STEP 6 When: WEEK FOUR Some banding processes may vary slightly within the organization given the area of care and its unique needs, such as ED, Peri-Operative, Radiology, L&D, etc. You will want to contact the directors of each of these areas and ask if they have their own P&P for banding a patient or if they use the facility-wide P&P. If they have a unique P&P, obtain a copy of it so you can compare its content with the facility-wide P&P. Review with each area that has a unique P&P their current P&P and the proposed changes. Other Notes / Cues Contact ED Director. Name/ext: Unique P&P? No Yes (obtain copy) Contact Peri-Op Director. Name/ext: Unique P&P? No Yes (obtain copy) Contact Radiology Director. Name/ext: Unique P&P? No Yes (obtain copy) Contact L&D Director. Name/ext: Unique P&P? No Yes (obtain copy) Contact other Director. Name/ext: Unique P&P? No Yes (obtain copy) Contact other Director. Name/ext: Unique P&P? No Yes (obtain copy) STEP 7 When: WEEK FOUR Get this item on P&P committee agenda and obtain approval for the changes. Coordinate this with the departments that have unique P&Ps so all are changed at the same time. P&P Committee Contact /ext. Date/Month on P&P Committee Agenda Other Notes / Cues Communicate the P&P Committee date to other pertinent directors so the proposed changes are reviewed and agreed upon before P&P Committee date. 14 Color-Coded Alert System Standardization in Virginia

15 Suggested Task Chart for Facility Preparation Area #3 Hospital Specific Documentation STEP 8 If any other steps required, add them here. Other Notes / Cues STEP 9 If any other steps required, add them here. Other Notes / Cues STEP 10 If any other steps required, add them here. Other Notes / Cues Patient safety is sound clinical practice 15

16 Suggested Task Chart for Facility Preparation: STEP 1 Area #4 Staff and Patient Education When: TWO to THREE WEEKS Familiarize yourself with training content and the tools (FAQs, brochures, posters, etc.). Other Notes / Cues Review the Educational Materials in this Toolkit. This is important because as discussions occur about who will do what, you can inform directors about the educational materials that are available for staff to use. Because the Educational Materials section is so comprehensive, some may opt to participate in the facilitation process. By giving the directors all the information about the tools and training section in this manual, they can make a better informed decision. STEP 2 When: WEEK THREE or FOUR Determine the education format by discussing with the education department and clinical directors. Education format refers to the way the education will be managed at the unit-specific level or in a general session where multiple departments are present. Also, is the education going to be facilitated through the department specific directors or the education department? It is important to consider all stakeholders and departments: physicians, dietary, pharmacists, therapists, radiology, periop, ED, labor and delivery, housekeeping, etc. The column on the right is a tool that you will need for all the stakeholders. Other Notes / Cues Education Department preferences are: Unit Specific General session Other (explain ) Facilitator Preferences: Unit Based Educ Dept Critical Care Director preferences are: Unit Specific General session Other (explain ) Facilitator Preferences: Unit Based Educ Dept Med/Surg Director preferences are: Unit Specific General session Other (explain ) Facilitator Preferences: Unit Based Educ Dept Pharmacy Director preferences are: Unit Specific General session Other (explain ) STEP 3 When: THREE or FOUR WEEKS Obtain the names of the trainers and send an advising of an upcoming Train the Trainer session. This meeting should be no longer than 45 minutes to one hour. Schedule this about one month out. Other Notes / Cues Whether training occurs at a unit-based level or in a general session, a Train the Trainer session ought to be considered so the Education Materials and Training Tips can be viewed by all. 16 Color-Coded Alert System Standardization in Virginia

17 Suggested Task Chart for Facility Preparation: STEP 4 Area #4 Staff and Patient Education When: THREE to FOUR WEEKS Find out who is chairman of the Patient/Community Education Committee. Contact that person and schedule appointment to review the patient brochure. If necessary, get on the agenda of the next committee meeting to get approval for the brochure to be used. Other Notes / Cues Most organizations have a Patient/Community Education Committee that reviews educational materials before they are given to patients. STEP 5 When: TWO WEEKS before Train the Trainer Session Make one copy of the Educational Materials section of this Toolkit for each trainer so they each have their own set of materials. Don t forget about the PowerPoint presentation, too. A PowerPoint presentation is included in this toolkit and is available online at Other Notes / Cues This Toolkit may be updated periodically based upon user feedback or when new information is obtained. Be sure to visit the web site where the Toolkit is posted and check for any updates before you make copies of materials. The web site is: STEP 6 When: THREE WEEKS before Staff Education Roll-out Remind trainers via to make copies of the following handouts for their staff: Staff education brochure Patient education brochure Frequently Asked Questions (FAQs) Posters announcing the meeting (there are three to choose from) Sign-in sheet Competency checklist (if you are using) Other Notes / Cues Some facilities require that any changes to forms be reviewed through a Forms Committee or similar entity. Other facilities do not require this process if changes are minimal or they do not change content. This step is to determine your facility s process. STEP 7 When: WEEK THREE or FOUR Other Notes / Cues Patient safety is sound clinical practice 17

18 Staff Education Training Tips Introduction The following section has been developed knowing that you may choose to utilize all or part of the information provided. We hope that we have made this section comprehensive without being overly burdensome. Make this plan work for you; use what you want and remember the goal is to communicate the changes with color-coded alert wristbands to your staff. This section was designed with the following objectives: 1. Staff can be easily guided through the changes with color-coded alert wristbands. 2. The instructors are well equipped to educate staff about these changes. 3. No new materials have to be created by staff; this should be nearly a turn key education event. 4. Most importantly, staff can feel confident that all Virginia hospitals and nursing homes are hearing the same message and a similar implementation plan. (This is important if staff work at more than one facility.) Key Preparation Before You Start Review the Implementation Work Plan to be sure you have included all of your stakeholders in this process. Consider all the stakeholders in your organization who are affected by the changes in color-coded wristbands. Thoughts to consider: 1. While ultimately the nurses are the people that usually band the patient, the health unit clerks (HUC) are involved in the process. Include them in the training. They can better assist the nurses when they have this information. 2. Consider the housekeeping staff. They are often present in a patient room when a patient is trying to get up or walking to the bathroom. If the housekeeping staff knows a yellow wristband means Fall Risk, and they see a patient trying to get up, they can call the nursing staff, alert them and potentially prevent a fall. 3. What about the dietary technicians? A red wristband means there is an allergy and not just to medicines. Maybe it is a food allergy and the red band will alert them to check for that and note it in their profile. 4. Don t make assumptions about the medical staff and/or nursing facility staff getting this information. Attendings, intensivists, residents and interns need to know what these colors mean. Pull them into the process. This promotes safe health care for all providing it and receiving it. 5. Who else? Take some time to quietly observe daily activities at one of the nurse s stations. In a 30-minute observation you probably will see and hear things that identify another stakeholder. Include them in the education process. Once done, you can begin the actual training. 18 Color-Coded Alert System Standardization in Virginia

19 Getting Started Most people will use this toolkit as the main teaching material. It contains most of the pertinent information staff need to know for this initiative. We suggest you do not give out the brochure until the end of your training because people may start reading the brochure instead of listening to you. Pass it out at the end of the meeting, but tell them up front that they will receive a copy of the information you are presenting. Here are the main points you want to make during your training session: 1 Start with a story People want to know why they should do something; simply telling them they need to start doing this because they do is not sufficient information to get high levels of compliance. Besides, isn t that what you would want to know, too? A story gives them information that makes the request relevant so they want to comply. In 2005, a hospital in Pennsylvania submitted a report to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing an event in which clinicians nearly failed to resuscitate a patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as DNR (do not resuscitate). The source of the confusion was that a nurse had incorrectly placed a yellow wristband on the patient. In this hospital, the color yellow signified that the patient should not be resuscitated. In a nearby hospital, in which the nurse also worked, yellow signified restricted extremity, meaning that this arm is not to be used for drawing blood or obtaining IV access. Fortunately, in this case, another clinician identified the mistake, and the patient was resuscitated. However, this near miss highlights a potential source of error and an opportunity to improve patient safety by reevaluating the use of color-coded wristbands. We want to acknowledge this hospital for its transparency and disclosure of this event. It could have happened anywhere, and it has served as a wake up call to many of us. 2 Follow the story with data results Sharing how Virginia hospitals and nursing homes use wristbands makes the information more relevant and reinforces to them their motivation to comply and participate in this initiative. Share this information with staff. It is on one of the panels in the brochure, too. A survey was conducted in September 2008 of Virginia hospitals and nursing homes to evaluate our risk for such an event. The results showed that 53% of Virginia s hospitals and nursing homes use color-coded wristbands; however, 94% do not use purple for DNR; 52% do not use red for Allergy; and 83% do not use yellow for Fall Risk, Our risk was apparent. Our answer is to implement standardization in all Virginia hospitals and nursing homes. 3 The Big Picture For many individuals, knowing that we are part of a bigger and unique situation fosters pride and again reinforces the motivation to comply. Share with them: This initiative is being adopted by hospitals and nursing homes statewide benefitting clinicians and our patients. Efforts are underway around the country to implement standardization in other states. The colors are uniform in all of the states. RED means ALLERGY YELLOW means FALL RISK PURPLE means DNR Patient safety is sound clinical practice 19

20 4 Introduce the Colors In the Toolkit you will find three sample wristbands that show the colors and preprinted text being used. If your organization uses a different vendor (check with Materials Management) than you may want to check to see if their bands are available so you can show what you will be using. The colors should be the same since the vendors know the colors being used. This is the time to show the bands so there is a visual of the information you are going to share. Review with staff the three bands, the colors and the corresponding meaning. The text below will walk you through that information. There are three different color-coded alert wristbands that we are going to discuss that are a part of the statewide standardization. RED means ALLERGY YELLOW means FALL RISK PURPLE means DNR or Do Not Resuscitate Other facility-specific alert wristbands that your organization uses may be introduced, such as latex allergy or restricted extremity. 5FAQs about the colors selected This is a companion document to the staff brochure. Research about colors and human association with certain colors contributed to the color selection process in the nationwide trend to standardize. This is important for staff to know so they can feel confidant with this process. The FAQ document reviews why the colors were selected and why other colors were not selected. At this time, hand out the FAQ sheet to staff and review with them. You are two-thirds done at this point. Let staff know this so they mentally relax. 20 Color-Coded Alert System Standardization in Virginia

21 6 Seven Risk Reduction Strategies In addition to the standardization of wristband colors in the state, we recommend seven other risk reduction strategies that should be initiated. These are suggested as a result of sentinel events that have occurred, near-miss events and common sense. This information is also in the staff brochure, and is available as a template that can be cut out as a Quick Reference Guide and laminated if you desire. Review these with staff now. Color-Coded Alert Wristbands Risk Reduction Strategies Quick Reference Card 1. Use wristbands with the alert message pre-printed (such as DNR ). 2. Remove any social cause colored wristbands (such as Live Strong ). 3. Remove wristbands that have been applied from another facility. 4. Initiate banding upon admission, changes in condition or when information is received during hospital stay. 5. Educate patients and family members about the wristbands and what they mean. 6. Coordinate chart/white board/care plan/door signage information/stickers, etc., with same color-coding. 7. Educate staff to verify patient color-coded alert wristbands upon assessment, hand-off of care and facility transfer communication. Quick Reference Cards can be printed from the template provided on your Toolkit CD. The following information takes each risk reduction strategy and provides further detail and/or explanation of that strategy. 1. Use wristbands that are pre-printed with text that b. Remind them that color-coding provides another tells what the band means. opportunity to prevent errors. a. This reinforces the color-coding system for new c. Use the Patient/Family Education brochure located clinicians, helps caregivers interpret the meaning in this Toolkit. of the band in dim light and helps those who may 6. Coordinate chart/white board/care plan/door be colorblind. signage information/stickers, etc., with same colorcoding, b. This eliminates the chance of confusing colors for allergies, fall prevention and DNR with alert messages. status. 2. Remove any social cause (such as Live Strong, 7. Educate staff to verify patient color-coded alert Cancer, etc.) colored wristbands. wristbands upon assessment, hand-off of care and a. Address this in your facility s policy. facility transfer communication. b. If that can t be done, you can cover the band with a 8. When possible, limit the use of colored wristbands. bandage or medical tape, but removal altogether is a. Such as for other categories of care (e.g., latex, best. MRSA, tape). 3. Remove wristbands that have been applied by 9. Remember, the wristband is a tool to communicate another facility. an alert status. a. This should be done during the entrance to facility a. Educate staff to utilize the patient, medical process and/or admission. record information (physician order for DNR) as b. Address this in your facility s policy. resources for verification for allergies, fall risk and 4. Initiate banding upon admission, changes in advance directives. condition or information received during hospital 10. If your facility uses pediatric wristbands that stay. correspond to the Broselow color-coding system 5. Educate patients and family members regarding for pediatric resuscitation, take steps to reduce purpose and meaning of the wristbands. any confusion between these Broselow colors and the colors on the wristbands used elsewhere in the a. Including the family in this is a safe guard for you facility. and the patient. Patient safety is sound clinical practice 21

22 7 Teaching Patients The patient education brochure is a companion document to the staff brochure. We know that how we say something is just as important as what we say. We need to communicate to them in a respectful and simple way without being condescending. The following text was written to serve as a script for staff so everyone could be delivering the same information to patients and families. By having a consistent message, we reinforce the information; this helps patients and families retain the information. Another benefit of having a consistent message is that patients and families experience a sense of confidence in the health care system. The text below is taken directly from the staff brochure. This is the time to mention to staff there is a patient/ family brochure that can be handed out (if you intend to do that). Tell staff you will hand out the brochure to them so they can see what the patients will have when you are done presenting the material. SCRIPT for any staff person talking to a patient or family What is a Color-Coded Alert Wristband? Color-coded alert wristbands are used in hospitals and nursing homes to quickly communicate a certain health care status or condition that a patient may have. This is done so every staff member can provide the best care possible. What do the colors mean? There are three different color-coded alert wristbands that we are going to discuss because they are most commonly used. RED means ALLERGY If a patient has an allergy to anything food, medicine, dust, grass, pet hair, ANYTHING tell us. It may not seem important to you but it could be very important in the care they receive. YELLOW means FALL RISK We want to prevent falls at all times. Nurses review patients all the time to determine if they need extra attention in order to prevent a fall. Sometimes, a person may become weakened during his illness or because he just had surgery. When a patient wears this color-coded alert wristband, the nurse is saying this person needs to be assisted when walking to prevent a fall. PURPLE means DNR Or Do Not Resuscitate Some patients have expressed an end-of-life wish and we want to honor that. 22 Color-Coded Alert System Standardization in Virginia

23 8 And finally. Review with staff the points below. These are the items on the competency checklist so it is important to clarify that they have a good understanding of these items. You should emphasize their impact on staffs tasks every day and review those points. This is a good time to hand out your facility s policies and procedures. Be sure your policy covers the areas listed below as they also are a part of the competency. If your policy does not address one or more of the items on the competency, than you should remove those items from the form. Color-Code what do the three colors mean? Who can apply the wristband to the patient? When is the color-coded wristband(s) applied? Policy on removal of social cause wristbands. Patient education and how to communicate (script) the information with patients/families. Need for re-application of wristband. Communication regarding wristbands during transfers and for other reports. Patient refusal to comply with policy. Discharge instructions for home and/or facility transfer. Visit to download the Toolkit. Patient safety is sound clinical practice 23

24 Staff Education The Tools These materials are available on your Toolkit CD and also on the VHHA web site at 1. Staff Training/Meeting Posters (Employee Poster - 20minutes.pdf, Employee Poster - GotColor.pdf, Employee Poster - MatchGame.pdf) Poster announcing the initiative and training meeting dates/times. Post in the staff lounge, communication boards, employee locker room, staff bath rooms or wherever staff will see it. 2. Staff Sign-In Sheet (Eduction Staff Sign-in Sheet.pdf) Use this form so there is a record of all staff that attended the training session. Make copies so you don t use the last one. Keep this sign in sheet with your staff meeting/training folder. The Joint Commission or other regulatory agencies may ask you for it. This is especially important if you are making this a mandatory participation session. 3. Staff Education Regarding Color-Coded Alert Wristbands tri-fold brochure (CC Alert Staff Brochure.pdf) Most people will use this brochure as the main teaching material. It contains most of the pertinent information staff need to know about this initiative. We suggest you pass out the brochure at the end of your training, but tell them up front that there is a brochure with all of the information you are presenting, and you will pass it out later. 4. FAQ handout for staff (FAQ Sheet.pdf) This handout was created to offer further clarification regarding the changes being made. You can use this as a handout and to post in staff areas. 5. Staff competency checklist (Education Staff Competency Checklist.pdf) We recognize that some organizations will opt to use this form and some will not. Should you decide to use a competency checklist in your process, we hope this form will provide the documentation you need. This form also serves as a great checklist for the trainer so all of the important elements in the training are remembered and taught. If you do not use this as a staff form, consider using it to help you remember every element you should be reviewing with staff about the changes with the color-coded alert wristbands. 6. Patient Safety: Understanding what your color-coded Alert wristband means tri-fold brochure in English (CC Alert Patient Brochure English.pdf, CC Alert Patient Brochure English Generic.pdf) This brochure was created to educate patients and family members about the wristband colors and what they mean. Patients should have this information whether they need a color-coded wristband or not, because they may provide staff with updates to their information following this education. For example, perhaps a patient has an allergy to a certain food but was thinking only about medications when first asked about allergies. During a family visit, a loved one could read the patient safety brochure and bring up the food allergy. This can now be corrected and the patient is not at risk due to an oversight. There are two versions of the English and Spanish brochures in this Toolkit and on the CD. One is customizable to insert your facility name and logo, the other is generic. 7. Patient Safety: Understanding what your color-coded Alert wristband means tri-fold brochure in Spanish (CC Alert Patient Brochure Spanish.pdf, CC Alert Patient Brochure Spanish Generic.pdf) All of the educational materials are contained in this toolkit and are in PDF format for ease of copying in color or black and white. They also are available on the Internet at 24 Color-Coded Alert System Standardization in Virginia

25 Got Color? Join us on the following dates for the training sessions about color-coded alert wristbands. Day / Date / Time: Location: Day / Date / Time: Location: Day / Date / Time: Location: Questions? Contact: ext.

26 MATCH GAME Colors are FUN but patient safety is NOT A GAME Join us on the following dates for the training sessions about color-coded alert wristbands. Day / Date / Time: Location: Day / Date / Time: Location: Day / Date / Time: Location: DNR ALLERGY FALL RISK Questions? Contact: ext.

27 20 minutes will tell you what to expect with the new changes Join us on the following dates for the training sessions about color-coded alert wristbands. Day / Date / Time: Location: Day / Date / Time: Location: Day / Date / Time: Location: Questions? Contact: ext.

28 Staff Sign-In Sheet Date: Unit/Dept/ Location: Educator: Topic: Objective: Color-Coded Alert Wristbands 1. To inform staff of the new process and colors of the Allergy, Fall Risk and DNR wristbands. 2. Staff to demonstrate understanding of information through feedback of information. Name Title Shift

29 Other Risk Reduction Strategies Staff Should Know Color-coded Alert Wristbands / Risk Reduction Strategies Quick Reference Card 1. Use wristbands with the alert message pre-printed (such as DNR ). 2. Remove any social cause colored wristbands (such as Live Strong ). 3. Remove wristbands that have been applied from another facility. 4. Initiate banding upon admission, changes in condition or when information received during hospital stay. 5. Educate patients and family members regarding the wristbands. 6. Coordinate patient chart/white board/care plan/door signage information/stickers with same color-coding. 7. Educate staff to verify patient color-coded alert arm bands upon assessment, hand-off of care and facility transfer communication. For more information, visit Staff Education Regarding: Color-coded alert wristbands Information intended for all staff, clinical and non-clinical.

30 How this all got started In 2005, a hospital in Pennsylvania submitted a report to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing an event 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 the confusion was that a nurse had incorrectly placed a yellow wristband on the patient. In this hospital, the color yellow signified that the patient should not be resuscitated. In a nearby hospital, in which 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 in this case, another clinician identified the mistake, and the patient was resuscitated. However, this near miss highlights a potential source of error and an opportunity to improve patient safety by re-evaluating the use of color-coded wristbands.* We want to thank and acknowledge this hospital for its transparency and disclosure of this event. It could have happened anywhere, and it has served as a wake up call to many of us. What about Virginia? A survey was conducted in September 2008 of Virginia hospitals and nursing homes to evaluate our risk for such an event. The results showed wide variations in colors and methods to convey alerts. Our risk was apparent. Virginia is following the nationwide standardization colors: Red = Allergy, Yellow = Fall Risk and Purple = DNR in all nursing homes and hospitals. RED means ALLERGY ALERT YELLOW means FALL RISK PURPLE means DNR How to tell the patients what the different colors mean How we say something is just as important as what we say. The next column is a script you can use to tell your patients/ families about the color-coded alert wristbands and what they mean. If everyone says it the same, there is a better chance patients and families will understand what we are saying. SCRIPT For any staff person talking to a patient or family What is a Color-Coded Alert Wristband? Color-coded alert wristbands are used in hospitals and nursing homes to quickly communicate a certain health care status, condition or an alert that a patient may have. This is done so every staff member can provide the best care possible. What do the colors mean? There are three different color-coded alert wristbands that we are going to discuss because they are the most common ones used. RED means ALLERGY If a patient has an allergy to anything food, medicine, dust, grass, pet hair, ANYTHING tell us. It may not seem important to you but it could be very important in the care they receive. YELLOW means FALL RISK We want to prevent falls at all times. Nurses review patients all the time to determine if they need extra attention in order to prevent a fall. Sometimes a person may become weakened during their stay or because they just had surgery. When a patient has this color-coded alert wristband, the nurse is saying this person needs to be assisted when walking or they may fall. PURPLE means DNR Or Do Not Resuscitate Some patients have expressed an end-of-life wish and we want to honor that. *View the entire report at advisory_dec_14_2005.pdf

31 Q A FAQs about Color-Coded Alert Wristbands Why should we consider adopting these wristband colors? An increasing number of health care providers are not facility-based staff, and wristband colors may differ not only from hospital-to-hospital or nursing hometo-nursing home, but also from hospital-to-hospital in a health system. Given that many health care staff work at more than one facility and that patients may be transferred between facilities, there is a potential for confusion and possible medical error. Standardization is an important and logical step to improve patient safety in our facilities. Q We don t use wristbands for DNRs at this facility. Why should we consider adopting this? Wristbands are used in most Virginia hospitals and A nursing homes to communicate an alert. Registry staff, travelers, non-clinical staff, etc., may be unaware of where to look in the medical record if they are new to your facility. By having a wristband on, a quick warning is communicated so anyone could know about this alert. Additionally, it also is a means to communicate to the family that we are clear about their end-of-life wishes. By not having a band on, errors of omission could potentially be created. Q A If we adopt these standardized wristbands, do we still need to look in the chart? Yes. Code status or fall risk can change throughout a patient stay. It is important to know the current status so the patient s and families wishes can be honored. Always validate that there is an order by a physician for the DNR designation. (See question below on Allergy wristband.) Q For the Allergy wristband, do we write the specific allergies on the wristband? No it is our recommendation that allergies be written in the medical record according to your facility s A policy and procedures. We suggest allergies not be written on the wristband for several reasons: 1. Legibility may hinder the correct interpretation of the allergy listed; 2. By writing allergies on the wristband someone may assume the list is comprehensive. However, space is limited on a wristband. The risk is that some allergies would be inadvertently omitted leading to confusion or missing an allergy; 3. Throughout a patient stay, allergies may be discovered by other caregivers, such as dieticians, radiologists, pharmacists, etc. This information is typically added to the medical record and not always a wristband. By Q A having one source of information to refer to, such as the medical record, staff of all disciplines will know where to add newly discovered allergies. Why even use an alert band for Fall Risk? According to the Centers for Disease Control and Prevention (CDC), falls are an area of great concern in the aging population. According to the CDC: 1. More than a third of adults aged 65 years or older fall each year. 2. Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes. 3. Of those who fall, 20% to 30% suffer moderate to severe injuries that reduce mobility and independence and increase the risk of premature death. 4. In 2000, the total direct cost of all fall injuries for people 65 and older exceeded $19 billion. The financial toll for older adult falls is expected to increase as the population ages, and may reach $54.9 billion by 2020 (adjusted to 2007 dollars). 5. In 2004, there were more than 320,000 hospital admissions for hip fractures, a 3% increase from the previous year. However, from 1996 to 2004, after adjusting for the increasing age of the U.S. population, the hip fracture rate decreased 25% (from 1,060 per 100,000 population to 850 per 100,000 population). Over 90% of hip fractures are caused by falling, most often by falling sideways onto the hip. In 1990, researchers estimated that the number of hip fractures would exceed 500,000 by the year Q A How were these colors chosen? Arizona was the first state in the country to implement statewide standardization. These colors were chosen after significant research on their part, and the nationwide trend has been to standardize to the same color models. For questions or comments regarding this project, please direct to the Virginia Hospital & Healthcare Association: Sheila Gray Assistant Vice President P.O. Box Richmond, VA (804) sgray@vhha.com

32 Staff Competency Checklist Purpose: These are the standards of the technical competencies necessary for performance and/or clinical practice. To meet competency standard the employee must demonstrate proficiency in performing the technical procedures safely as evidenced by department specific criteria. Methods to Use: A. Demonstration B. Direct Observation/Checklist C. Video / Powerpoint Review D. Skills Lab E. Self Study/Test F. Data Management G. Other Employee Name Job Title Supervisor s initials signify competency was met. Patient Color-coded Alert Wristband Process Color Code what do the three colors mean? Date Method Used Supervisors Initials Comments Who can apply the wristband to the patient? When does the application of the wristband(s) occur? Policy on patient s not allowed to wear the Social Cause bands Patient education and how to communicate (script) the information with patients /families Need for Re-Application of Band Communication regarding wristbands during transfers and other reports Patient refusal to comply with policy Discharge Instructions for home and /or facility transfer Signature Initials Signature Initials Employee Signature Date We wish to acknowledge the Pennsylvania Color of Safety Task Force, which developed the initial form that is the basis for this document.

33 [Name of hospital/nursing home] is proud to be a supporter of this collaborative work to improve the quality and safety of the care we provide to our patients. Your Logo Here This initiative is just one way Virginia s hospitals and nursing homes are improving the care provided to our patients. Providing quality care and improving patient safety are part of our mission. For more information, visit Patient Safety: Understanding what your color-coded alert wristbands mean

34 Statewide Patient Safety Initiatives Virginia s hospitals and nursing homes have a strong partnership when it comes to providing quality health care to the patients they serve. This statewide wristband standardization is just one way we are working together to improve the quality and safety of care to our patients. What is a Color-Coded Alert Wrist Band? Alert wristbands are used in hospitals and nursing homes to communicate quickly a certain health care status or an alert that a patient may have. This is done so every staff member can provide the best care possible, even if they do not know that patient. The different colors have certain meanings. The words for the alerts also are written on the wristband to reduce the chance of confusing the alert messages. What do the different colors mean? There are three different color-coded alert wristbands that have been standardized in Virginia. RED means ALLERGY ALERT If a patient has an allergy to anything food, medicine, dust, grass, pet hair, ANYTHING tell us. It may not seem important to you but it could be very important in the care they receive. YELLOW means FALL RISK We want to prevent falls at all times. Nurses review patients all the time to determine if they need extra attention in order to prevent a fall. Sometimes, a person may become weakened during their stay or because they just had surgery. When a patient has this color-coded alert wristband, the nurse is saying this person needs to be assisted when walking or they may fall. PURPLE means DNR or Do Not Resuscitate Some patients have expressed an end-of-life wish and we want to honor that. Involving Patients and Family Members It is important that the patient and families know these colors and their meanings because you are the best source of information. Keep us informed. If there is information we do not know, such as a food allergy or a tendency to lose balance and almost fall, share that with us because we want to provide the best and safest health care to all of our patients. Also, if you have an Advance Directive, tell us. An Advance Directive tells your doctor what kind of care you would like if you become unable to make medical decisions. We want to respect and honor a patient s wishes and that is done best when we have all of the information.

35 We are proud to be a supporter of this collaborative work to improve the quality and safety of the care we provide to our patients. This initiative is just one way Virginia s hospitals and nursing homes are improving the care provided to our patients. Providing quality care and improving patient safety are part of our mission. For more information, visit Patient Safety: Understanding what your color-coded alert wristbands mean

36 Statewide Patient Safety Initiatives Virginia s hospitals and nursing homes have a strong partnership when it comes to providing quality health care to the patients they serve. This statewide wristband standardization is just one way we are working together to improve the quality and safety of care to our patients. What is a Color-Coded Alert Wrist Band? Alert wristbands are used in hospitals and nursing homes to communicate quickly a certain health care status or an alert that a patient may have. This is done so every staff member can provide the best care possible, even if they do not know that patient. The different colors have certain meanings. The words for the alerts also are written on the wristband to reduce the chance of confusing the alert messages. What do the different colors mean? There are three different color-coded alert wristbands that have been standardized in Virginia. RED means ALLERGY ALERT If a patient has an allergy to anything food, medicine, dust, grass, pet hair, ANYTHING tell us. It may not seem important to you but it could be very important in the care they receive. YELLOW means FALL RISK We want to prevent falls at all times. Nurses review patients all the time to determine if they need extra attention in order to prevent a fall. Sometimes, a person may become weakened during their stay or because they just had surgery. When a patient has this color-coded alert wristband, the nurse is saying this person needs to be assisted when walking or they may fall. PURPLE means DNR or Do Not Resuscitate Some patients have expressed an end-of-life wish and we want to honor that. Involving Patients and Family Members It is important that the patient and families know these colors and their meanings because you are the best source of information. Keep us informed. If there is information we do not know, such as a food allergy or a tendency to lose balance and almost fall, share that with us because we want to provide the best and safest health care to all of our patients. Also, if you have an Advance Directive, tell us. An Advance Directive tells your doctor what kind of care you would like if you become unable to make medical decisions. We want to respect and honor a patient s wishes and that is done best when we have all of the information.

37 [Name of hospital/nursing home] se enorgullece en apoyar este trabajo en equipo para mejorar la calidad y seguridad del cuidado que proporcionamos a nuestros pacientes. Your Logo Here Queremos agradecer al Registro Estándar por su servicio de traducción de este folleto. Agradecemos el apoyo brindado a esta iniciativa de seguridad del paciente. Esta iniciativa es sólo una forma en la que los hospitales y los hogares de convalecencia de Virginia están mejorando el cuidado que proporcionamos a nuestros pacientes. Proporcionar cuidados de calidad y mejorar la seguridad del paciente son parte de nuestra misión. Seguridad del paciente: Comprender lo que significan los brazaletes con alertas codificadas por color

38 Iniciativas estatales de seguridad del paciente Los hospitales y hogares de convalecencia de Virginia comparten una unión sólida al momento de proporcionar cuidados para la salud de calidad a los pacientes a los que tratan. La estandarización de los brazaletes a nivel estatal es sólo una forma en la que trabajamos juntos para mejorar la calidad y la seguridad del cuidado de nuestros pacientes. Qué es un brazalete con alertas codificadas por color? Los brazaletes con alerta se usan en los hospitales y los hogares de convalecencia para comunicar de forma rápida el estado de salud o la alerta que un paciente puede tener. Esto se hace para que todos los miembros del personal puedan proporcionar el mejor cuidado posible, incluso si no conocen a ese paciente en particular. Los distintos colores tienen ciertos significados. Las palabras de la alerta también están escritas en el brazalete para reducir el riesgo de confundir los mensajes de alerta. Qué significan los distintos colores? Existen tres brazaletes distintos con alerta codificada por color que se estandarizaron en Virginia. ROJO significa ALERTA POR ALERGIA Si el paciente es alérgico a algo (alimento, medicamento, polvo, pasto, pelo de mascota, CUALQUIER COSA) por favor díganoslo. Puede que no parezca importante para usted, pero puede serlo para el cuidado que va a recibir AMARILLO significa RIESGO DE CAÍDAS Queremos prevenir las caídas en todo momento. Las enfermeras revisan al paciente todo el tiempo para determinar si necesita atención adicional para prevenir caídas. Algunas veces, una persona puede debilitarse durante su estancia o por que acaba de ser operada. Cuando un paciente tiene este brazalete con alerta codificada por color, la enfermera indica que la persona requiere asistencia para caminar o puede caer. MORADO significa No resucitar (Do Not Resuscitate o DNR) Algunos pacientes han expresado su deseo de finalizar su vida y deseamos respetarlo. Involucrar a los pacientes y a sus familiares Es importante que los pacientes y las familias conozcan estos colores y su significado por que usted es la mejor fuente de información. Manténganos informados. Si hay información que no conocemos, como una alergia a algún alimento o una tendencia a perder el equilibrio y casi caer, compártala con nosotros porque queremos proporcionar los mejores y más seguros cuidados de la salud a nuestros pacientes. También, si cuenta con Instrucciones Anticipadas, por favor díganoslo. Las Instrucciones Anticipadas le dicen al médico qué tipo de cuidado usted desea, en caso de que sea incapaz de tomar una decisión médica. Queremos respetar y llevar a cabo los deseos de los pacientes y lo podremos hacer mejor si contamos con la información.

39 Esta iniciativa es sólo una forma en la que los hospitales y los hogares de convalecencia de Virginia están mejorando el cuidado que proporcionamos a nuestros pacientes. Proporcionar cuidados de calidad y mejorar la seguridad del paciente son parte de nuestra misión. Queremos agradecer al Registro Estándar por su servicio de traducción de este folleto. Agradecemos el apoyo brindado a esta iniciativa de seguridad del paciente. Seguridad del paciente: Comprender lo que significan los brazaletes con alertas codificadas por color

40 Iniciativas estatales de seguridad del paciente Los hospitales y hogares de convalecencia de Virginia comparten una unión sólida al momento de proporcionar cuidados para la salud de calidad a los pacientes a los que tratan. La estandarización de los brazaletes a nivel estatal es sólo una forma en la que trabajamos juntos para mejorar la calidad y la seguridad del cuidado de nuestros pacientes. Qué es un brazalete con alertas codificadas por color? Los brazaletes con alerta se usan en los hospitales y los hogares de convalecencia para comunicar de forma rápida el estado de salud o la alerta que un paciente puede tener. Esto se hace para que todos los miembros del personal puedan proporcionar el mejor cuidado posible, incluso si no conocen a ese paciente en particular. Los distintos colores tienen ciertos significados. Las palabras de la alerta también están escritas en el brazalete para reducir el riesgo de confundir los mensajes de alerta. Qué significan los distintos colores? Existen tres brazaletes distintos con alerta codificada por color que se estandarizaron en Virginia. ROJO significa ALERTA POR ALERGIA Si el paciente es alérgico a algo (alimento, medicamento, polvo, pasto, pelo de mascota, CUALQUIER COSA) por favor díganoslo. Puede que no parezca importante para usted, pero puede serlo para el cuidado que va a recibir AMARILLO significa RIESGO DE CAÍDAS Queremos prevenir las caídas en todo momento. Las enfermeras revisan al paciente todo el tiempo para determinar si necesita atención adicional para prevenir caídas. Algunas veces, una persona puede debilitarse durante su estancia o por que acaba de ser operada. Cuando un paciente tiene este brazalete con alerta codificada por color, la enfermera indica que la persona requiere asistencia para caminar o puede caer. MORADO significa No resucitar (Do Not Resuscitate o DNR) Algunos pacientes han expresado su deseo de finalizar su vida y deseamos respetarlo. Involucrar a los pacientes y a sus familiares Es importante que los pacientes y las familias conozcan estos colores y su significado por que usted es la mejor fuente de información. Manténganos informados. Si hay información que no conocemos, como una alergia a algún alimento o una tendencia a perder el equilibrio y casi caer, compártala con nosotros porque queremos proporcionar los mejores y más seguros cuidados de la salud a nuestros pacientes. También, si cuenta con Instrucciones Anticipadas, por favor díganoslo. Las Instrucciones Anticipadas le dicen al médico qué tipo de cuidado usted desea, en caso de que sea incapaz de tomar una decisión médica. Queremos respetar y llevar a cabo los deseos de los pacientes y lo podremos hacer mejor si contamos con la información.

41 1. Purpose Virginia Policy and Procedure Template Policy name: Color-Coded Wristbands To have a standardized process that identifies and communicates patient-specific risk factors or special needs by standardizing the use of color-coded wristbands based upon the patient s assessment, wishes and medical status. 2. Objectives A. To reduce the risk of potential for confusion associated with the use of color-coded wristbands. B. To communicate patient safety risks to all health care providers. C. To include the patient, family members and significant others in the communication process and promote safe health care. D. To adopt the following risk reduction strategies: 3. Definitions 1. A preprinted written descriptive text is used on the bands clarifying the intent (e.g., Allergy, Fall Risk, or DNR ) 2. No handwriting is used on the wristband. 3. Colored wristbands may only be applied or removed by a nurse or licensed staff person conducting an assessment. 4. If labels, stickers or other visual cues are used in the medical record to communicate risk factors or wristband application, those cues should use the same corresponding color and text to the colored band. 5. Social cause wristbands, such as Live Strong, should not be worn in the hospital or nursing home setting. Staff should have family members take the social cause wristbands home or remove them from the patient and store them with his other personal items. This is to avert confusion with the color-coded wristbands and to enhance patient safety practices. 6. To assist the patient and his family members to be a partner in the care provided and safety measures being used, patient and family education should be conducted regarding: a) The meanings of the color-coded wristbands and the alert associated with each wristband. b) The risks associated with wearing social cause wristbands and why they are asked to remove them. The following represents the meaning of each color-coded band: Band Color Red Yellow Purple Communicates Allergy Fall Risk DNR 4. Identification (ID) Bands in Admission, Pre-Registration Procedure and/or Emergency Department The colorless or clear admission ID wristbands are applied in accordance with procedures outlined in organizational policy on patient ID and registration. These ID bands may be applied by non-clinical staff in accordance with organizational policy. 5. Color-Coded Bands During the initial patient assessment, data is collected to evaluate the needs of the patient and a plan of care unique to the individual is initiated. Throughout the course of care, reassessment is ongoing which may uncover additional pertinent medical information, trigger key decision points, or reveal additional risk factors about the patient. It is during the initial and reassessment procedures that risk factors associated with falls, allergies and DNR status are identified or modified. Because this is an interdisciplinary process, it is important to identify who has responsibility for applying and removing color-coded bands, how this information is documented and how it is communicated. The following procedures have been established to remove uncertainty in these processes:

42 A. Any patient demonstrating risk factors on initial assessment will have a color-coded wristband placed on the same extremity as the patient ID band by the nurse or licensed professional, if the nurse is unavailable. For hospitals, this includes all in-patient, outpatient and emergency department patients. B. The application of the band is documented in the chart by the nurse, per hospital policy. C. If labels, stickers or other visual cues are used to document the actual medical record, the stickers should correspond to band color and text. D. Upon application of the wristband, the nurse will instruct the patient and his family member(s) (if present) that the wristband is not to be removed. E. In the event that any color-coded wristband(s) have to be removed for a treatment or procedure, a nurse will remove the bands. Upon completion of the treatment or procedure, new bands will be made, risks reconfirmed and the wristbands placed immediately by the nurse. 6. Social Cause Wristbands Following the patient ID process, a licensed clinician, such as the admitting nurse, examines the patient for social cause wristbands. If social cause wristbands are present, the nurse will explain the risks associated with the wristbands and ask the patient to remove them. If the patient agrees, the band will be removed and given to a family member to take home or stored with the other personal belongings of the patient. If the patient refuses, the nurse will request the patient sign a refusal form acknowledging the risks associated with the social cause wristbands (see attached document). In the event that the patient is unable to provide permission, and family member(s) or a significant other is not present, the licensed staff member may remove the band(s) in order to reduce the potential of confusion or harm to the patient. 7. Patient / Family Involvement and Education It is important that the patient and family members are informed about the care being provided and the significance of that care. It also is important that the patient and his family member(s) be acknowledged as a valuable component of the health care team. Including them in the wristbands process will assure a common understanding of what the wristbands mean, how care is provided when wristbands are worn and their role in correcting any information that contributes to this process. Therefore, during assessment procedures, the nurse should take the opportunity to educate and re-educate the patient and his family members about: a) The meanings of the wristbands and the alert associated with each wristband; b) The risks associated with wearing social cause wristbands and why patients are asked to remove them. c) To notify the nurse whenever a wristband has been removed and not reapplied. d) When a new wristband is applied and they have not been given explanation as to the reason. Patients and families have available to them a patient/family education brochure that explains this information as well. 8. Hand-Off in Care The nurse will reconfirm color-coded wristbands before invasive procedures, at transfer and during changes in level of care with patient/family, other caregivers and the patient s chart. Errors are corrected immediately. Color-coded wristbands are not removed at discharge. For home discharges, the patient is advised to remove the band at home. For discharges to another facility, the bands are left intact as a safety alert during transfer. Receiving facilities should follow their policies and procedures for the banding process. 9. DNR (Do Not Resuscitate) DNR (Do Not Resuscitate) status and all other risk assessments are determined by individual facility policy, procedure and/or physician order written within and acknowledged within that care setting only. The color-coded wristband serves as an alert and does not take the place of an order. Do Not Resuscitate orders must be written and verification of Advanced Directives must occur.

43 10. Staff Education Staff education regarding color-coded wristbands will occur during the new orientation process and reinforced as indicated. (Note to Hospitals/Nursing Homes: You should insert your specific language in this section so it matches your annual processes and competencies, should you decide to include color-coded wristbands in that process.) 11. Patient Refusal If the patient is capable and refuses to wear the color-coded band, an explanation of the risks will be provided to the patient/family. The nurse will reinforce that it is their opportunity to participate in efforts to prevent errors, and it is their responsibility as part of the team. The nurse will document in the medical record patient refusals, and the explanation provided by the patient or his family member. The patient will be requested to sign an acknowledgement of refusal by the completion of a release.

44 Acknowledgement of Refusal Release Form Patient Identifier Information Name: PID: DOB: Admitting {Facility Name} {Form Number} Patient Refusal to Participate in the Wrist Band Process The above named patient refuses to: (check what applies) q q 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 Live Strong and others). The risks of refusing to remove the Social Cause colored wristbands have been explained to me by a member of the health care team. I understand that by refusing to remove the Social Cause wristbands it could cause confusion in my care, and despite this information, I do not give permission for the removal of the Social Cause colored wristbands. Reason provided (if any): Date / Time Signature / Relationship Date / Time Witness Signature / Job Title VHHA wishes to acknowledge the Pennsylvania Color of Safety Task Force, which developed the initial form that is the basis for this document.

45 Vendor Information VHHA has selected Precision Dynamics Corporation (PDC) as the preferred vendor to supply wristbands for this standardization initiative. Since its inception in 1956, PDC has set the standards as a pioneer in patient safety through positive identification solutions as the first company to create a single-piece patient ID Wristband, the first bar coded wristband system and the first Smart Band RFID wristband system. Today, PDC s continued commitment to quality and customer satisfaction has secured its reputation as the leading provider in the global health care marketplace for patient identification products. Product Ordering Instructions Please contact your Materials Management department to order wristbands. VHHA members discount pricing is applied to orders, VHHA members and affiliates must complete the attached Authorized Distributor (AD) Selection Form. Please return the completed form via fax to (804) attention: David Jenkins. Once received, VHHA will fill in your Membership and LIC Numbers and notify your selected distributor. You may select your current distributor for this process. Please allow 30 days after submitting the AD Selection Form before placing orders to ensure your distributor has loaded the pricing information into their system. Non-VHHA members who wish to participate will receive the same discount pricing through Precision Dynamics by filling out the following documents and faxing to (804) (attention: David Jenkins): Authorized Distributor (AD) Selection Form Customer Enrollment Form VHHA Participation Agreement Final pricing may vary slightly depending upon selected distributor mark-up. In order for the colors of the wristbands to match from facility-to-facility, your vendor will need the following: Allergy Band Red PMS 1788 ALLERGY in Black Arial Bold, 48 pt. All Caps Fall Risk Band Yellow PMS 102 FALL RISK in Black Arial Bold, 48 pt. All Caps DNR Band Purple PMS 254 DNR in White Arial Bold, 48 pt. All Caps For questions related to specific product information, please contact your Precision Dynamics representatives below: Ed Hammer Fay Pollock Eastern Regional Sales Manager Sales Precision Dynamics Corporation Precision Dynamics Corporation (800) Ext (800) Ext (609) Cell edh@pdcorp.com For questions related to obtaining VHHA Member discount pricing, contact VHHA Services: David Jenkins (804) djenkins@vhha.com Patient safety is sound clinical practice 45

46 AD SELECTION FORM PRIMARY OR SECONDARY VHHA Patient Identification Wristband/Alert Standardization Program Schedule 1: Authorized Distributor (AD) Selection Form Provista members that desire to access distributed Novation/Provista product agreements, available through the voluntary VHHA GPO Program, must complete this Authorized Distributor (AD) Selection Form. Your Membership Number: LIC #: System/Network Name: Facility Name: Address: Director of Materials Management: Phone Number: Fax Number: Declared Authorized Distributor: POL City/State: Date: Primary Service Type: Acute care Long-term care I hereby declare as Participating Member s acute care Authorized Distributor. I hereby declare as Participating Member s non-acute care Authorized Distributor. Note: Participating Members may select one Authorized Distributor for both acute care and non-acute care or may designate a separate Authorized Distributor for non-acute care. * I hereby declare the above Authorized Distributor as a: primary participant secondary participant X Director of Materials Management: AD Representative: Date: * To ensure discount pricing, VHHA members and member affiliates must select a secondary authorized distributor (to be named above) for placing wristband orders. This can be members and affiliate members current distributor. Note: A 45-day notification process is required by Novation to notify the manufacturer to add a new participant to a purchasing agreement or distribution agreement. If you are re-signing with your existing distributor, you need to allow at least 30 days for pricing verification between your organization and your distributor. Please fax completed form to: VHHA Services (804) Internal Use Only Submitted By: David Jenkins, VHHA Phone No.: (800) Member ID No.: PROVISTA Date: VHHA to fax AD Selection Form to Provista Member Services at (972)

47 CUSTOMER ENROLLMENT FORM CUSTOMER INFORMATION: CUSTOMER NAME VHHA CHANNEL PARTNER NAME CUSTOMER ADDRESS (PO Box Address Not Valid) CITY STATE ZIP CODE CUSTOMER TELEPHONE NUMBER CUSTOMER FAX NUMBER FEDERAL TAX ID NUMBER AHA ID NUMBER *+ ADJUSTED PATIENT DAYS *+ LICENSED BED COUNT *+ OPERATING BED COUNT *+ * Per American Hospital Association (AHA) Guide + Please provide information if membership class of trade equals Acute CUSTOMER ELIGIBILITY: The Customer identified above will be eligible to participate in PROVISTA Contracts and Programs (where no commitment document is required) within 45 days after announcement to the appropriate Supply Partner(s). Some Supply Partners require completion of specific commitment or participation forms prior to contract access. Upon receipt of these completed commitment forms, the customer identified above will be eligible to participate in that specific agreement within 45 days after notification to the Supply Partner. All completed AD and commitment forms will be posted on PROVISTA Forms Manager within 24 business hours. CUSTOMER TYPE: (Please select one Customer Type) STAND ALONE: An independent facility with no affiliates or satellites SYSTEM: A facility that owns, leases, and/or manages affiliates/satellites SATELLITE: A facility owned, leased or managed by another PROVISTA Customer. Enter System Name or MID#: CUSTOMER CLASS OF TRADE and PRIMARY DESCRIPTION: Check ( ) one class of trade AND check ( ) one Primary Description: ACUTE Cancer Hospital Cardiac Hospital General Medical & Surgical Long Term Care Acute Hospital Psychiatric Hospital Rehabilitation Hospital Surgical Hospital AMBULATORY Ambulatory Surgery Center Imaging Center Dialysis Laboratory Post Surgical Recovery Oncology/Radiation Center MANAGED CARE PLAN Corrections Facility Group Model HMO Managed Care Plan Staff Model HMO HOME HEALTH Home Health Services Home Infusion Center Hospice LONG TERM CARE Assisted Living Facility Long Term Care Nursing Home Skilled Nursing Sub-Acute Facility PHYSICIAN PRACTICE Allergy & Immunology Anesthesiology Cardiovascular Disease Dental Dermatology Ear, Nose & Throat Family Practice Gastroenterology Geriatric Medicine Infectious Disease Internal Medicine Multi-Specialty Neurology Obstetrics & Gynecology Ophthalmology Orthopedic Pain Management Pathology Pediatrics Physical Medicine& Rehabilitation Plastic Surgery Podiatry Psychiatry Pulmonary Disease Radiology Rheumatology Urology Vascular Surgery PHARMACY/RETAIL Pharmacy/Retail & Closed Pharmacy/Retail PROPERTY MGMT UNIVERSITY/COLLEGE/SCHOOL CLINICS PRIMARY CUSTOMER CONTACT INFORMATION: (Required to process enrollment) CONTACT NAME (PRINT) CONTACT TITLE CONTACT ADDRESS PHONE# PROVISTA Sales Rep Initials: FAX TO PROVISTA MEMBER SERVICES: (972)

48 Virginia Hospital Shared Services Corporation ( VHHA Services ) Member/Affiliate Participation Agreement This Agreement is made this day of, 2009, by and between the Virginia Hospital Shared Services Corporation (VHSSC). VHHA Services and, Member/Affiliate. VHSSC, d/b/a VHHA Services, was founded by the Virginia Hospital & Healthcare Association (VHHA) in 1980 to develop services, programs and vendor relationships that help Virginia hospitals and health integrated delivery systems enhance clinical, financial and operational performance. As the shared services affiliate of VHHA, VHHA Services negotiates vendor and distribution agreements on behalf of its Members and affiliates. Member or member affiliate hereby and hereafter referred to as ( Member ) is an organization which promotes or utilizes vendor and distribution agreements negotiated by VHHA Services. Therefore, in consideration of the foregoing statements, VHHA Services and Member agree as follows: A. By completion of this Agreement, Member agrees to participate in VHHA Services contracts to the extent of their needs. Member authorizes VHHA Services to advise the manufacturers that they should be listed as a participating Member in VHHA Services contracts. B. Term and Termination. This Agreement is for the term commencing on the date set forth above. The effective date of program eligibility will be established for each program. This Agreement may be terminated by either party at will and without cause any time upon 90 days prior written notice to the other. C. Member agrees that VHHA Services is authorized (but not obligated) to enter into any agreement with suppliers in order to make such products, intangible rights to services available to the Member. Any such agreement may set forth some or all of the terms and conditions pursuant to which the Member may purchase goods, rights, or services from the supplier. Nothing in any such agreement shall, in any way, obligate the Member to purchase, license or lease any goods, services, or intangible rights hereunder. In each case, where the Member takes advantage of such agreement, the Member agrees to comply with the terns and conditions (of such agreements). Member recognizes that before they may purchase through such agreement, VHHA Services may need to ensure that its vendors are willing to do business with the Member. 1 of 2 5/01/08

49 D. Member agrees that VHHA Services may receive remuneration from vendors or suppliers in connection with any products, rights or services which are purchased, licensed, or leased in accordance with Title 42, U.S. Code, Section 1320a-7b (b) (3) (A) and the rules and regulations promulgated thereunder, including without limitation, remuneration for providing marketing, distribution and promotion services to the Member institution. E. VHHA Services shall not be liable to the Member for any act, or failure to act, in connection with VHHA Services purchasing agreements, any distribution agreement or VHHA Services programs. In addition, VHHA Services shall not have any liability to Member for any failure of a distribution agent to perform the service, which it has agreed to provide in any distribution agreement. Without limiting the generality of the foregoing, VHHA Services hereby disclaims and excludes any express or implied representation or warranty regarding any goods or services which may be subject of VHHA Services purchasing agreements, or any distribution agreement, or VHHA Services programs. F. This Agreement may NOT be transferred or assigned without the written consent of both parties hereto. THEREFORE, in consideration of the premises and the covenants contained herein and other good and valuable consideration, the adequacy, receipt and sufficiency whereof and hereby acknowledged, the parties agree to the Terms outlined. IN WITNESS WHEREOF, the parties have caused this Agreement to be executed and delivered by their respective authorized representatives. Member Name: Title Date: VHHA Services / Provista Cannel Partner Name: Title Date: 2 of 1 5/01/08