A Cognitive Analysis of Color-Coded Wristband Use in Health Care

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.