Hospital wristband color standardization
Color-coded wristbands are visual cues that inform health care providers about hospitalized patients’ circumstances such as elevated fall risk, allergies, or do-not-resuscitate (DNR) status, prompting providers to consult medical records for full details. Color-coded wristbands are often used as part of multi-component approaches to patient safety. Many hospitals use the color scheme recommended by the American Hospital Association (AHA): red for allergy, yellow for elevated fall risk, and purple for DNR status1. Some hospitals also use pink to warn of a restricted extremity which cannot be used for blood draws or blood pressures2. However, color codes vary across hospitals3.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved patient safety
What does the research say about effectiveness?
There is insufficient evidence to determine whether standardizing the color codes of hospital wristbands improves patient safety. Anecdotal reports suggest that the potential for provider confusion decreases and patient safety increases following standardization of wristband colors1, 2, 4. Lack of standardization can introduce patient safety issues when health care providers work in multiple facilities (e.g., travel nurses, students on medical rotations) with conflicting color codes, such as the possibility of a do-not-resuscitate (DNR) status being misidentified5. However, some experts express concerns regarding the use of color-coded wristbands, which can be difficult to discern at a distance, in low light or when obscured, and can go unnoticed during a crisis6. Additionally, approximately one in 12 men and one in 200 women suffer from color blindness7, and health care providers with color blindness can find it challenging to use color-coded information in medical care8. Additional evidence is needed to confirm effects.
Experts suggest that providers routinely consult patients’ charts along with wristband cues1, ensure wristbands are updated as needed to reflect patients’ medical status6, and verify wristbands during all provider shift changes2. To aid in implementation, wristbands should be included in standard trainings during new staff orientation and annual education for current staff, wristbands should be stored in plain sight at nurses’ stations as a reminder for use, and there should be periodic random spot checks of wristband accuracy2. Furthermore, cause-related wristbands (i.e., Livestrong bracelets) should be removed upon admission to reduce the possibility of provider confusion4.
A UK-based study suggests color-coded wristbands that indicate the targeted oxygen range for patients receiving supplemental oxygen can remind providers to monitor oxygen statistics, improving the safe prescription of oxygen9.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact standardizing the color-coding of hospital wristbands can have on disparities in health care; there is no data available about which disparities color-coded wristbands could address.
What is the relevant historical background?
Health care providers such as travel nurses may work across health care systems, regions, or even state lines to fill care gaps due to provider shortages, particularly in underserved or rural areas14. Each location may have different color-coding for patient wristbands, creating potential patient safety issues1, 5.
Calls for hospital wristband color-coding standardization began with a 2005 incident in Pennsylvania. A nurse working in two hospitals with two different color-coding systems incorrectly placed a do-not-resuscitate (DNR) wristband on a patient instead of one for limb restrictions; the patient subsequently experienced cardiac arrest and nearly died. This patient safety incident led hospitals across Pennsylvania to begin standardizing color-coded wristbands2, 5, 15, and in 2008 the American Hospital Association (AHA) released a quality advisory recommending that all hospitals standardize the colors used for alert wristbands while still urging providers to refer to patients’ charts for verification1.
Equity Considerations
- How can your hospital or hospital system partner with administrators, state hospital associations, nursing organizations, and/or medical associations to gain support for standardization efforts to improve patient safety?
Implementation Examples
As of 2023, at least 20 states use the wristband color-coding recommendations from the American Hospital Association (AHA): yellow for fall risk, red for patient allergies, and purple for do-not-resuscitate (DNR) patient preferences5.
The Texas Hospital Association (THA), in collaboration with the Texas Organization of Nurse Executives, Texas A&M Health Science Center Rural and Community Health Institute, and the TMF Health Quality Institute created the Color-coded Wristband Standardization Project in Texas toolkit, which features a work plan for implementation, wristband specifications for vendors, and staff and patient education materials10. THA follows the colors recommended by the AHA10, as does the Wisconsin Hospital Association11, and Jefferson Regional Medical Center in Arkansas, which provides information for patients about the safety implications of color-coded wristbands on their website12.
The Institute for Clinical Systems Improvement (ICSI) and the Agency for Healthcare Research and Quality (AHRQ) multi-component fall prevention efforts are two examples of widely used efforts that include color-coded wristbands. These programs also use signs on patients’ doors and white boards, notes above beds, and color-coded, nonskid socks (yellow for fall risk, red for high fall risk) to indicate fall status13.
Implementation Resources
‡ Resources with a focus on equity.
WHA-WI - Wisconsin Hospital Association (WHA). The color of safety: Standardization and implementation manual. Madison: Wisconsin Hospital Association (WHA).
THA-Wristband initiative - Texas Hospital Association (THA). Wristband standardization initiative: Resources.
Footnotes
* Journal subscription may be required for access.
1 AHA-Wristbands 2008 - American Hospital Association (AHA). AHA Quality advisory on implementing standardized colors for patient alert wristbands. Washington, D.C.: American Hospital Association (AHA); 2008.
2 Sturdivant 2019 - Sturdivant T, Johnson P. Protecting restricted extremities: The implementation of a pink wristband. Nephrology Nursing Journal. 2019;46(4).
3 Dixon-Woods 2016 - Dixon-Woods M, Pronovost PJ. Patient safety and the problem of many hands. BMJ Quality & Safety. 2016;25(7):485-488.
4 US FDA-Maisel 2021 - Maisel WH. Use purple bracelets or wristbands only for do not resuscitate status - letter to industry. Silver Spring, MD: Division of Industry Communication and Education, Center for Devices and Radiological Health, U.S. Food and Drug Administration (U.S. FDA); August 16, 2021.
5 CHPSO-Color-coded wristbands - Hospital Quality Institute, Collaborative Healthcare Patient Safety Organization (CHPSO). Ask CHPSO: Do hospitals use color-coded wristband identification and, if so, what colors do they use? Quality Quarterly. 2023.
6 Wood 2011 - Wood SD, Bagian JP. A cognitive analysis of color-coded wristband use in health care. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2011;55(1):281-285.
7 NIH-Color blindness - National Institutes of Health (NIH), National Eye Institute. Color blindness.
8 Nelson 2019 - Nelson B. Color blindness in the medical workplace. Cancer Cytopathology. 2019;127(4):209-210.
9 Forster 2016 - Forster S, Smith S, Daniel P, et al. Optimising prescription and titration of oxygen for adult inpatients using novel silicone wristbands: Results of a pilot project at three centres. Clinical Medicine. 2016;16(4):330-334.
10 THA-Wristband initiative - Texas Hospital Association (THA). Wristband standardization initiative: Resources.
11 WHA-WI - Wisconsin Hospital Association (WHA). The color of safety: Standardization and implementation manual. Madison: Wisconsin Hospital Association (WHA).
12 JRMC-Patient safety - Jefferson Regional Medical Center (JRMC). Patient safety: Understanding what your color-coded “alert” wristband means. Pine Bluff, Arkansas.
13 AHRQ-RAND Ganz 2013 - Ganz DA, Huang C, Saliba D, et al. Preventing falls in hospitals: A toolkit for improving quality of care. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2013.
14 Yang 2022 - Yang YT, Mason DJ. COVID-19’s impact on nursing shortages, the rise of travel nurses, and price gouging. Health Affairs Forefront. 2022.
15 PSQH-Lalande 2014 - Lalande F. Standardization of color-coded alerts: Time for a national effort. Patient Safety & Quality Healthcare (PSQH). 2014.
Related What Works for Health Strategies
To see all strategies:
countyhealthrankings.org/whatworks