In this paper we examine human factors involved in the use of color-coded wristbands by analyzing cases that resulted in adverse events. We consider such cases in terms of which stage of care the events occurred, the health care roles involved in the event, and the cognitive factors seen as most likely to be causative in the event. We discuss a common theme in this analysis, that perhaps we are expecting too much from color-coding, and propose a number of possible solutions and suggestions for improving patient safety. We conclude that relying on color alone for any health care task is both risky and ineffective.
Get full access to this article
View all access options for this article.
References
1.
BagianJ.P.LeeC.ColeJ.: A method for prioritizing safety related actions. In Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care. Chicago: National Patient Safety Foundation, 1999, pp. 176–185.
2.
BoydJ.Patterns Of Conflict, December1986. Unpublished study, 196 pages.
3.
CarterR. C.CahillM. C. (1979). Regression models of search time for color-coded information displays. Human Factors, 21, 293-302.
4.
EdworthyJ.AdamsA. (1996). Warning design: a research prospective. London: Taylor and Francis.
5.
EndsleyM. R. (1995). A Taxonomy of Situation Awareness Errors. Lubbock, TX: Texas Tech University.
6.
GosbeeJ.DeRosierJ. (2002). Oxygen (Compressed Gas) Cylinder Hazard Summary. VA National Center for Patient Safety.
7.
GosbeeJWGosbeeLL (Eds.). (2010). Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, 2nd Ed.Oakbrook Terrace: Joint Commission Resources.
8.
HayesS.Wristbands called patient safety risk. St. Petersburg Times. December10, 2004;1A.
9.
MillerG. A. (1956). The magical number seven plus or minus two: some limits on our capacity for processing information. Psychological Review, 63(2), 81-97.
10.
SandersM.McCormickE. (1993). Human Factors In Engineering and Design: McGraw-Hill.
11.
SeghalN.L.WachterR.M. (2007). Identification of Inpatient DNR Status: A Safety Hazard Begging for Standardization. Journal of Hospital Medicine, 2(6), 366-371.
12.
SperryR. W. (1952). Neurology and the mind-brain problem. American Scientist, 40, 291 - 312.
13.
WickensC. D.HollandsJ. G. (2000). Engineering Psychology and Human Performance (3 ed.). Upper Saddle River, NJ: Prentice-hall.
