click for large versionSource: Pennsylvania Patient Safety Authority
Table 1. Variance of Medical “Messages” and Colors Used on Patient Wristbands in Pennsylvania Hospitals.
“Even a warning that is effective by itself may get buried when there are others hanging around it,” Dr. Bogner says. “There is no hierarchy of importance in most hospitals because there is no central authority making sure that red, for instance, is saved only for a warning about the most dangerous incidents.”
Often specialists are responsible for signs relating to their area of expertise without taking into account the addition to the chaos as well as how the warning will fit in with the realities of the hospital unit. Clutter in the ICU and other areas of the hospital can be exacerbated by multiple disciplines putting up their own signs. There is no method for hospitalists to look around and see which warnings pertain to them.
“There is a reason why all stop signs are red and have eight sides,” Dr. Grace says. “[It] makes it easy to for all to recognize at a glance what is being communicated. In hospitals, the same warning may be many different shapes and colors. This can make it hard for hospitalists, especially those who go to more than one hospital, to know what is being said and the response expected.”
Placement of visual warning signs can add to the confusion and limit effectiveness. Information is best placed near where it is to be used. For example, a sign telling staff that a certain extremity should not be used for blood draws is more likely to be seen and acted upon if it is in the form of a wristband attached to the arm instead of a warning sign on the door. It also is important to have easy access to the tools needed to follow the warning sign’s directions.
“Hospitals don’t have the resources to put a fully stocked isolation cart near every door,” Dr. Grace says. “You get a busy doctor down the far end of the hall and they may decide to just pop in and see their patient for a second, instead of taking the long walk back to the cart. Others follow the lead of the physician and, eventually, there will be a real need for the protection and it won’t be worn. The outcome is an increase in cluster outbreaks.”
Regulatory Requirements
Some of what one of the experts called “the metastasis of signage” can be laid at the feet of the various organizations that regulate healthcare in the U.S. For example, many signs and their placement are required by regulators with, as one hospital risk management expert says, little or no understanding of the impact the mandates have on sign pollution.
“There are guidelines from The Joint Commission and others indicating when you have to put signs up, and often mandate both their content and placement,” says Elaine Ziemba, managing director of risk management at the Stanford Hospitals and Clinics in Palo Alto, Calif. “Environmental health and safety people will decide signage related to medical gasses and fire safety, and biomedical engineering will make decisions related to their equipment.”
Warning signs are added according to the perceived needs of the specific discipline involved. Risk managers are not routinely consulted about warning signs and notices put up around her hospital, Ziemba says. There also is little guidance in the literature about the effectiveness of multiple warning signs, especially when compared with the wide range of studies that assess alert fatigue in electronic medical record systems.