From the February 26, 2004 issue

Problem: 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 purpose.

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 point.

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.

References: (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.