Certain AirLife Broselow Rainbow Tapes (Revision 3, 36-23446) contain incorrect medication doses, listing vecuronium 0.1 mg/ml instead of the correct 0.1 mg/kg dose, and flumazenil as 0.1mg/kg rather than the correct 0.01 mg/kg dose. These errors involve high-risk medications and could lead to dangerous tenfold overdoses, including neuromuscular blockade complications or increased seizure risk with flumazenil. Organizations using this tape should immediately assess their supplies, implement risk-mitigation strategies, and educate staff about the error.
- Problem: Incorrect values for high-risk medications (vecuronium, flumazenil) and defibrillation settings, potentially causing tenfold overdoses or severe underdosing in pediatric patients. The tapes are widely used by emergency department and prehospital providers to estimate the weight of a child rapidly when other weight based methods are not available.
- Call to Action Required: Please take steps to mitigate use and contact Manufacturer AirLife (call 1-800-433-2797 or email productquality@myairlife.com).