Let’s Save Patients by Standardizing the Standardized Colors
Color coding is a frequently-used visual management method — one that generally works great (unless you're color blind). Hospitals usually have a set of “codes” that are called on the PA system and staff are given a badge hanger as pictured at left. We have similar examples and cases where staff have applied “kaizen” thinking to improve the use of these color codes in our upcoming book Healthcare Kaizen.
But what happens when the colors aren't the same at different hospitals and somebody works in different organizations? It happens…
This article from Louisiana caught my eye last week: “Hospital color codes still not standardized.”
From the story:
A hospital per diem nurse who worked at two different hospitals started her shift one night only to find a patient had gone into cardiac arrest. She screamed, “Code blue! Code blue!,” over the telephone-intercom, and instead of receiving assistance from other medical employees, she was surrounded by armed security guards within minutes. The nurse didn't realize that code blue at this particular Washington state facility meant security alert.
When seconds count in life-and-death situations, we can't afford errors like this. The article points out that many states don't have standardized codes for all hospitals, as somebody said, “Most hospitals will have their own standardized systems.”
Their own… standardized…. so it's standardized, but not really standardized in the big picture.
Again, from the story:
As early as 2003, Maryland mandated all hospitals in the state follow the same uniform emergency codes per color. In 2009, both Washington state and Oregon hospitals standardized color-coded emergency response.
The article talks about “recommending” and “mandating.” How do we make this happen in our own states and our communities? Have you had any close calls due to this lack of standardization?