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Sehgal NL, Wachter RM. J Hosp Med. 2007;2:366-371.
This survey of nurse leaders at academic medical centers found great variation in the method used to document patients' do-not-resuscitate (DNR) status. Documentation could be found in the paper chart or electronic medical record, by means of a color-coded wristband, or combinations of these sources. Multiple wristband colors were used to indicate DNR status at different hospitals. This lack of standardization has been recognized as a patient safety problem, and resources exist to create standardized wristbands. The authors call for development of national standards for DNR documentation. In the same issue, the authors share an anecdote (see Associated Image link below) of a patient transferred from one acute facility to another with confusion that resulted from his multiple color-coded wristbands.
McCook A. Anesthesiology News. Sept 2011;37:9.
This news article highlights a program at Johns Hopkins Medicine that engages clinician reporting of errors and near misses to improve patient safety.