From the February 26, 2004 issue
Tools that help clinicians quickly
assess patients, select medications, doses, and equipment,
and monitor patients during resuscitation efforts, have the
potential to improve patient outcomes. During such critical
events, these tools can provide needed information quickly
and reduce reliance on memory and error-prone calculations
at a time when clinicians are already stressed. One such tool
is the Broselow tape (photo provided in PDF version), which
is used during pediatric emergencies to quickly estimate a
child's weight, determine weight-based drug doses, and select
the correct size emergency or resuscitation equipment.
While the Broselow tape has undoubtedly helped clinicians
save lives, several problems have previously been reported
when using the 1998 edition of the tape. Since volumetric
doses were often provided on the tape for quick reference,
clinicians sometimes administered the wrong dose because
the concentration of the drug in the cart did not match
the concentration listed on the tape. Thus, it became imperative
to stock code carts with the concentrations that were listed
on the tapes. While it's still important to standardize
the concentrations of medications stocked in code carts,
the newer 2002 tape prevents some of this confusion by listing
just the weight-based mg or mEq dose for most IV push medications.
Epinephrine is the only exception; the concentration (1:10,000
and 1:1,000), dose in mg, and the dose in volume are all
listed. On the other hand, the doses of medications administered
by continuous infusion are expressed in volume only. However,
directions for preparing the infusions precede these volumetric
(mL) doses, so the concentration and the mg dose can be
determined. Nevertheless, clinicians have expressed concerns:
one regarding the inconsistent methods used to express drug
doses (mg/mEq for IV push medications; mL for IV infusion
medications); and another about the lack of volumetric doses
for IV push drugs. This means that clinicians, often stressed
during an emergency, must perform a mathematical calculation
- albeit a rather simple one that may be facilitated by
the product labeling.
Another problem reported with the 1998 tape was occasional
confusion between the 3-5 kg zone and the 15-18 kg zone
on the tape. The 3-5 kg zone was not color-coded at all.
The 15-18 kg zone was color-coded "White." On
occasion, a clinician measuring a 3-5 kg child has mistaken
the lack of color in this weight zone as "White,"
which actually corresponds with the 15-18 kg zone. The equipment
for this higher weight category might quickly signal a mistake.
However, medications might be given at doses based on the
higher weight class before the mistake is recognized. On
the newer edition of the tape, a gray color is now used
in the 3-5 kg zone, but this zone directs clinicians to
use the "Pink/Red" zone equipment. Additionally,
the 3-5 kg zone is not distinctly labeled "Gray"
in the same way that the other zones are labeled with a
particular color (photo provided in PDF version). The gray
color distinguishes this section from the "White"
zone. Yet, we've heard that some clinicians are now referring
to the 3-5 kg zone as the "Gray" zone, and then
are looking for the corresponding "Gray" equipment,
which doesn't exist. Additionally, code carts with color-coded
drawers that match the colors on the tape (Armstrong Medical)
have a putty-colored top and bottom drawer (intended for
general use) that could be mistaken as a "Gray"
zone drawer, again causing delays in finding the right equipment.
A recently published article uncovered several other problems
when using the Broselow tape.(1) For example, during a series
of mock codes, the most common error observed was using
the tape upside down and measuring patients from the wrong
end. The authors observed this happening more frequently
in situations where the tape had been hanging on the code
cart or wall upside down. A serious misunderstanding was
also uncovered. Under each color-coded zone, there's a list
of several drugs useful for treating patients with seizures.
Another list provides drugs used for rapid sequence intubation.
Many clinicians believed these drugs represented an algorithmic
tool. Thus, during the mock codes, they gave more than one
medication from each list, believing they were to be given
in a sequence, rather than selecting one choice from among
the drugs listed.
Safe Practice Recommendation: Follow these recommendations
to reduce the risk of errors when using the Broselow tape
for pediatric emergencies.
Update tapes. Replace outdated Broselow tapes with
the most recent edition (2002).
Standardize concentrations. Provide standard concentrations
for resuscitation medications stocked in all pediatric code
carts. If using an older version of the tape, be sure drug
concentrations correspond with those listed on that version.
Organize carts. Stock medications and equipment in code
carts in a way that facilitates equipment retrieval according
to color-coded weight classes. Be sure to assess its effectiveness
in quickly guiding clinicians to the appropriate supplies.
Review cart contents. Require nurses who work with
pediatric patients to open code carts regularly to become
familiar with their contents, especially drugs and equipment
listed on the tape. Consider using a training cart for this
Facilitate proper measurement. Hang the tapes in
the proper orientation with the red arrow, stating "Measure
From This End," at the top. Teach staff to remember
"RED to HEAD" when aligning the tape to the patient's
body length during measurement. If the tape is laminated
in plastic, be sure the plastic sleeve does not extend beyond
the red arrow, potentially changing the measurement starting
Educate staff. Establish a standardized approach
to teaching clinicians how to use the Broselow tape and
develop a competency tool to validate proficiency.(2) Reeducate
clinicians when converting to an updated version of the
tape. Visit http://dukehealth1.org/deps/clinical_ed.asp
for helpful educational resources.
Alert staff to error potential. Provide clinicians
who may use the tape with ongoing information about the
types of errors that have happened to increase their sensitivity
to the risks of using this tool.
Assess preparedness. Hold mock codes in all pediatric
clinical areas to ensure appropriate use of the Broselow
tape. Perform a failure mode and effects analysis to uncover
other sources of potential confusion when using the tape.
(1) Hohenhaus SM, Frush KS. Pediatric patient safety: common
problems in the use of resuscitative aids for simplifying
pediatric emergency care. J Emerg Nurs 2004; 30:49-51. (2)
Hohenhaus S. Assessing competency: the Broselow-Luten resuscitation
tape. J Emerg Nurs 2002; 28:70-2.