Identification of Inpatient DNR Status: A Safety Hazard Begging for Standardization

Niraj L. Sehgal, MD, MPH; Robert M. Wachter, MD


Journal of Hospital Medicine. 2007;2(6):366-371. 

In This Article


Regardless of whether the DNR documentation occurs in paper or electronic form (and our study demonstrates significant practice variation in the documentation method), the risk that a hospitalized patient may suddenly stop breathing or become pulseless is ever present. When such a patient is discovered, providers race to the bedside and initiate care, but immediately ask, "Is the patient a full code?" In these often-chaotic moments, accurate and timely information about DNR status is critical to respecting a patient's preferences and avoiding a potentially devastating error. A number of the anecdotes shared by survey respondents and highlighted in Table 3 reinforce this concern. Many of these scenarios occur in the middle of the night or off a patient's primary unit (ie, at a test or procedure area), increasing the need for quick and easy identification of DNR status.

Our study demonstrates that a logical point-ofcare solution—a color-coded DNR patient wristband—may create its own safety hazards, particularly if the color designations are not known by all providers (including floating and traveling nurses or trainees who rotate at different hospitals) and if the colors being employed represent different indications at a given hospital (see accompanying Images Dx, page 445). We found that approximately 1 in 4 surveyed hospitals depict DNR status by a color-coded wristband. We also discovered remarkable variation in the colors chosen and the degree to which institutions use color-coded wristbands to signal a panoply of other patient-related issues. Human factors research demonstrates that even well-meaning patient safety solutions may cause harm in new ways if they are poorly implemented or if the interface between the technology and human work patterns is not well appreciated. For example, recent studies illustrate unintended consequences from safety-driven solutions, such as the implementation of computerized order entry,[21–22] quality measurement,[23] adoption of EHRs,[24] and bar code medication administration systems.[25] Because standardization is a key mechanism for decreasing the opportunities for error, our findings raise serious concerns about current wristband use.

Interestingly, the lack of standardization and its related risk of failing to recall the conditions associated with color-coded wristbands are complicated by societal trends. In December 2004 the issue of patient wristbands made headlines in Florida, when hospitals using yellow DNR wristbands (as was the case in 3 hospitals in our sample) reported several near-misses among patients wearing yellow Lance Armstrong Livestrong bracelets.[26–27] Given recent estimates that nearly 1 in 5 Americans wears these bracelets to support people living with cancer,[28] even safety-minded journals and national newspapers have highlighted the issue.[29–30] Most hospitals that continue to use yellow DNR wristbands now either remove or cover Livestrong bracelets at the time of hospital admission. Furthermore, many other self-help organizations now issue wristbands in a variety of colors as well, creating a potential hazard for any person wearing one in the hospital. Although patients do not mind wearing color-coded wristbands,[31] they might feel differently if they knew the potential for confusion.

After these anecdotal reports of identification mistakes surfaced, several states, most notably Arizona and Pennsylvania, launched initiatives to address the problem.[32]¯33] Arizona, after discovering 8 colors being used in the state, developed plans for a purple DNR color-coded wristband. The choice of purple, and the careful decision to avoid blue, occurred because many hospitals call their resuscitative efforts a "code blue," creating yet another potential source of confusion if a blue wristband is associated with a DNR order. The Pennsylvania Patient Safety Authority also found tremendous color variations in patient wristbands used in a statewide survey. Both states ultimately promoted standardized colors and indications and provided tool kits and implementation manuals.[32]¯33]

Although statewide initiatives represent a step forward, we believe that a national standard for color-coded wristbands would improve patient safety. Precedents for this call to action exist. For many years, anecdotal information circulated about the errors caused by ambiguous use of abbreviations, such as "qd" instead of daily or "U" instead of units. Individual hospitals often banned or limited the use of such abbreviations, but no standard list of high-risk abbreviations guided practice or required adherence, and cross-hospital variation undoubtedly led to confusion. In 2004 the Joint Commission created a uniform list of high-risk abbreviations as part of their National Patient Safety Goals, which instantly ended the debate about which abbreviations to ban and mandated compliance with the safety practice.[34] A national group of stakeholders should similarly be convened to develop a list of colors and associated conditions that should be widely disseminated and enforced by the Joint Commission or a similar body. The statewide efforts by Arizona and Pennsylvania are instructive in this regard. Despite being guided by the goal of standardization, these 2 states chose different colors for DNR identification (interestingly, Pennsylvania chose blue for DNR, perhaps for the same reason that Arizona avoided it­­code blue), further supporting the need for national guidelines ( Table 4 ).

Our study represents the first national sample of DNR identification practices. Although it targeted academic health centers and affiliated institutions, we believe that these practice variations likely exist in all health care settings. Our study limitations included reliance on self-reported institutional practices rather than direct review of existing policies and limited information about the surveyed population, making it impossible to compare respondents and nonrespondents. However, we have no reason to believe that these groups differed sufficiently to influence the study's main findings.

In the future, better technology may ultimately replace color-coded wristbands. For instance, the time may come when wireless technologies seamlessly linked to the electronic health record will alert providers to a patient's DNR status when entering the patient's room. However, for today, point-of-care solutions using color-coded wristbands remain a reasonable solution. Creating a nationally enforced standardized methodology, understandable and memorable to providers and free of stigma to patients (eg, a black wristband for DNR or writing "DNR" on a wristband) should be a patient safety priority. Because simplification is another key characteristic of safe systems, it seems prudent to aim for a national system that involves a maximum of 3-4 colors.


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