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​​In December 2005, risks were identified with using color-coded patient wristbands to communicate clinical information. Survey results showed while nearly four out of five facilities used color-coded patient wristbands, there is little consistency among facilities in the meanings associated with different colors.

In one case, a patient was nearly not resuscitated during cardiopulmonary arrest because she was incorrectly designated “DNR” with a colored wristband by a nurse who worked in multiple facilities and was confused about the meanings of different colors. The lack of consistency in wristband meanings and in how they are applied presents problems when patients are transferred among facilities and when patients are cared for by clinicians who work in multiple facilities.

Since this information was released, a group of healthcare organizations in northeastern and central Pennsylvania have started a grassroots effort to meet the challenge of making this practice safer.

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