Color-coding for multiples: A multidisciplinary initiative to improve the safety of multiples

Color-coding for multiples:

A multidisciplinary initiative to improve the safety of multiples

The Level III Neonatal Intensive Care Unit (NICU) in Rhode Island has an average daily census of 67 patients. The multidisciplinary NICU Medication Task Force works to decrease medication errors, develop easier processes and improve communication among healthcare providers.  Members of this Task Force work towards improving the safety of medication administration to the infants in the NICU and Newborn Nursery.  Review of occurrence screens revealed the number of medication incidents related to infants who are multiples.  There were 77 multiple deliveries during the first four months of 2006 (155 infants), and 13 occurrence screens related to medication incidents. Further analysis of the occurrence screens revealed that there were three occurrence screens related to delivery of medication to the wrong patient, with only one incident of the wrong medication actually given to the wrong baby. This reflected a 0.6% rate of occurrence screens related to actual wrong medication incidents. Errors related to testing and/or diagnostic testing for multiples was also experienced by the Laboratory and Diagnostic Imaging departments. 

As a result of these serious findings, the NICU Medication Task Force was expanded to incorporate additional team members, including Nursing Education and Administration from the Labor and Delivery area and the Mother/Baby units. The mission was to decrease errors and increase patient safety for this population. A creative solution, color-coding the infants was discussed as a solution to assist all staff to visually differentiate infant multiples on all units involved. The colors utilized for the multiples had to be different from any other color-coding that is used to identify patients with varying needs, including fall risk, medication allergy, etc. After choosing colors that did not conflict with color-coding patient identification already in use, the team decided to take this simplistic approach and apply it to the multiples. In the NICU the colored bands would not only be placed on the infant’s ankle, but also on the stethoscope, ambu-bags, bedside cards, medications, and supplies as infection control issues had also been identified.

Staff education was conducted on all necessary patient care units.  A policy and procedure reflecting these changes was instituted throughout the institution.  Since that time staff has reported the ease of recognition of the multiples. Laboratory and Diagnostic Imaging have reported no errors since the institution of the policy.  Pharmacy has seen a reduction in delivering the wrong medications to the wrong bedside. There were 182 multiple deliveries (375 infants) from May to December of 2006. The number of actual and potential occurrence screens were equal to that of the first four months of 2006, reflecting a 0.3% of occurrence screens representing actual errors. This represents a 50% reduction in actual medication errors involving multiples. As the population of multiples and the acuity of neonatal care increases it is imperative to have processes in place to insure patient safety.  The outcomes of the color-coding of multiples initiative reflect a successful process change to increase patient safety.