The Broselow–Luten Pediatric Safety System provides a standardized approach to pediatric emergency medical care, eliminating calculations and simplifying the ordering, preparation, and administration of medications. The following is a short self teaching module to familiarize you with basic features of the system…  

Patient Identification YELLOW DRUGS and EQUIPMENT Children are color coded according to patient weight. If the actual weight cannot be obtained the Broselow Tape is used. Patients are then identified with an armband and/or chart sticker. (next page) 1

Note, the patient is identified by 1) an actual color, 2) the color spelled out, 3) the weight in kilograms, 4) and reference to the relative size of the patient in the color scheme. 1 2 3 4 The patient is identified with appropriate arm bands and/or chart stickers.

dose in mgs (trade name) Generic Drug name, key word The Basic Rainbow The basic therapeutic informational unit of the Broselow-Luten System is the rainbow. The “rainbow” terminology describes the grouping of color coded zones, incorporating the various sizes of children. dose in mgs (trade name) Midazolam nasal Generic Drug name, key word 3 KG 4 KG 5 KG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN therapeutic informational unit = rainbow 3

The rainbow used by physicians for ordering is the milligrams rainbow (mg rainbow) and contains the individual dose pre-calculated in milligrams for each zone. For written orders the physician is encouraged to include the ‘Key words” along with the dose in mgs to help clarify the clinical indications considered in selecting the chosen dose. Key Words of the Safety Nomenclature 0.2 mg/kg (Valium) 3.3 mg 2.6 mg 2 mg 1.7 mg 1.3 mg WHITE YELLOW PURPLE RED PINK 1 mg 0.8 mg 0.6 mg 3 KG 4 KG 5 KG 6.6 mg 5.3 mg 4.2 mg GREEN ORANGE BLUE Diazepam Seizure IV White Key Words of the Safety Nomenclature Blow up of "mgs rainbows" Key words identify doses May use to order a dose by mgs or key word or may use to check a dose. 0.5 mg/kg (max 10) (Valium) 8 mg 6.5 mg 5 mg 4.2 mg 3.2 mg WHITE YELLOW PURPLE RED PINK 2.5 mg 2 mg 1.3 mg 3 KG 4 KG 5 KG 10 mg GREEN ORANGE BLUE Diazepam Rectal White mgs Rainbow

KEY WORD SAFETY NOMENCLATURE Safety nomenclature consists of key word qualifiers designed to differentiate and communicate the intended medication dose, even with drugs that have multiple doses*. If a drug has one or multiple indications, but all indications have the same dose, the dose is referred to as the reference dose. Midazolam reference IV (0.1 mg/kg) is the reference dose of this medication, used for sedation, anxiolysis, etc. If a drug has specialized indications requiring more than one dose(s) besides the reference dose, a specialized italicized keyword qualifier is added. Midazolam induction IV (0.3 mg/kg) has the italicized qualifier induction. It is used specifically for induction of anesthesia. Note the dose is three times the reference dose. Reference doses All indications utilize the same dose. “Diazepam reference 2.1 mg IV” is used for sedation, anxiolysis, muscle relaxation, etc. (0.1 mg/kg) for a child in the blue zone. Additional Key Word doses The drug has additional indication (s) besides the reference dose. “Diazepam seizure 4.2 mg IV” is for the anticonvulsant use (0.2 mg/kg) for the same child. * For a detailed explanation, see the reference materials (d.)

Lorazepam Seizure IV,IM Information for preparation and administration of each medication is contained in the mLs rainbows. These rainbows contain pre-calculated medication volumes in mLs from the preferred concentration formulation as well pertinent preparation and administration information. The full complement of the mLs rainbows are contained in the nurse’s mLs Rainbows Manual 0.1 mg/kg (Ativan) Lorazepam Seizure IV,IM 3 KG 4 KG 5 KG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN 0.3mg 0.4mg 0.5mg 0.7mg 0.9mg 1mg 1.3mg 1.7mg 2mg 2.7mg 3.3mg 2 mg/mL* 0.15 mL 0.2 mL 0.25 mL 0.35 mL 0.45 mL 0.5 mL 0.65 mL 0.85 mL 1 mL 1.4 mL 1.7 mL Dilute 1:1 with NS or D5W for IV doses, administer over 2-5 minutes. May repeat ½ dose in 10 minutes. Preparation and Administration Adverse reactions: bradycardia, circulatory collapse, hypotension or hypertension, respiratory depression, and apnea. Remarks mLs Rainbow *Note: the preferred concentration is listed as the concentration in milligrams per single mL and does not represent the total amount of medication contained in the vial (4mg/2 mL is the vial size containing 4 mg and the concentration is 2mg/mL). 5

The Tools….POC POC BOOKS Resuscitation The principal tools besides the Reference Manual for ordering ( which contain mgs rainbows) and mLs Rainbow Manual for preparation and administration (which contain mLs rainbows) are the Point of Care books (POC.) Each relates to a specific clinical situation and has helpful algorithms and flow charts which match their specific color coded information. In these books dosing information is presented both in the “rainbow” format but also in a “color page” format as well. (see next slide) . POC BOOKS Resuscitation Anaphylaxis RSI Seizures Procedural Sedation Antibiotics IV Antibiotics IM Selected Emergencies Fluids and Electrolytes Burns There are three errors which we are trying to decrease. The first is teh calculation error which we have been demonstrating. The second is the most common mistake adn that is taking an undue ammount of time. Why is it that an adult who needs dopamine gets it in a minute, while the same order in a child can take an hour? The third mistake is that people get nervous and may just not notice that the ET Tube has shifted. So, we decided that instead of just color -coding Mgs, or mLs, we would try to color code the entire process. We would like pediatric medicine to be mroe liek adult medicine. A doctor orders a drug by giving a "key word" and the system translated that key word and the child's "color" into so man mLs of a specific concentration, diluted adn administered in a standard, size related fashion. So how would we color-code the entire process? I'd like to show you with the following examples from various Point of Care references that help make up our system. POC books 6

“Color–Page” format : all information/drugs for a single color is contained on one page

Reference Manual Therapeutic rainbow mgs rainbow mLs rainbow Point of Care Guides

The Process 9

C is for Concentration: Color Coding Kids Safety Rules The Broselow-Luten System is a Patient Safety System. A mistake can be made in any system. However, if you always follow the Color Coding Kids Safety Rules, you will not make a mistake! These are the “CCK Safety Rules” C is for Color: Make sure the child’s color is correct. Make sure the matching color is selected in the B-L book or color page. C is for Concentration: When selecting proper mLs make certain the concentration of the drug matches the concentration in the Rainbow. K is for Key Words: Always chose the Rainbow with the matching key words. Let’s see how they work… 8

Lorazepam Seizure IV,IM “CCK Rules”… Orders can be obtained from the mgs rainbow or the Safety Nomenclature Card, which is a pocket card guide containing the key words and mg per kg dose (s) for each drug. -For written orders the physician is encouraged to include the ‘Key words” along with the dose in mgs to help clarify the clinical indications considered in selecting the chosen dose. -Verbal orders can be communicated by giving drug name and key word alone, ex. “Lorazepam Seizure IV”. 0.1 mg/kg (Ativan) Lorazepam Seizure IV,IM 3 KG 4 KG 5 KG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN 0.3mg 0.4mg 0.5mg 0.7mg 0.9mg 1mg 1.3mg 1.7mg 2mg 2.7mg 3.3mg mg Rainbow or.. Lidocaine reference IV 1 mg/kg Lidocaine Pain Prevention IV 0.5 mg/kg Lidocaine RSI IV 1.5 mg/kg Lorazepam reference IV, IM 0.05 mg/kg Lorazepam Seizure IV, IM 0.1 mg/kg Magnesium Sulfate reference IV 50 mg/kg Mannitol reference IV 1 g/kg Meperidine reference IV, IM 1 mg/kg Meropenem reference IV 60 mg/kg/day every 8 hours Meropenem Severe Infection IV 120 mg/kg/day every 8 hours Safety Nomenclature Card 10

Lorazepam Seizure IV,IM “CCK Rules”… INPUT PHASE The nurse locates drug name and key word in the mLs rainbow… POC 4 SEIZURES 0.1 mg/kg (Ativan) Lorazepam Seizure IV,IM 3 KG 4 KG 5 KG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN 0.3mg 0.4mg 0.5mg 0.7mg 0.9mg 1mg 1.3mg 1.7mg 2mg 2.7mg 3.3mg 2 mg/mL 0.15 mL 0.2 mL 0.25 mL 0.35 mL 0.45 mL 0.5 mL 0.65 mL 0.85 mL 1 mL 1.4 mL 1.7 mL …and then selects correct color to access the correct mg, mL column 11

Lorazepam Seizure IV,IM “CCK Rules”… PREPARATION PHASE The nurse then matches the selected drug concentration to the concentration in mLs Rainbow…. Lorazepam Seizure IV,IM 0.1 mg/kg (Ativan) 3 KG 4 KG 5 KG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN 0.3mg 0.4mg 0.5mg 0.7mg 0.9mg 1mg 1.3mg 1.7mg 2mg 2.7mg 3.3mg 2 mg/mL 0.15 mL 0.2 mL 0.25 mL 0.35 mL 0.45 mL 0.5 mL 0.65 mL 0.85 mL 1 mL 1.4 mL 1.7 mL …then draws up the corresponding correct mLs. 12

Lorazepam Seizure IV,IM “CCK Rules”… PREPARATION PHASE The order can be verified by a second nurse following the same process, checking that the mLs in the syringe match the mLs in the correct column and that the correct medication vial has been chosen. Lorazepam Lorazepam Seizure IV,IM 0.1 mg/kg (Ativan) 3 KG 4 KG 5 KG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN 0.3mg 0.4mg 0.5mg 0.7mg 0.9mg 1mg 1.3mg 1.7mg 2mg 2.7mg 3.3mg 2 mg/mL 0.15 mL 0.2 mL 0.25 mL 0.35 mL 0.45 mL 0.5 mL 0.65 mL 0.85 mL 1 mL 1.4 mL 1.7 mL 1 mL 2 mL 3 mL 4 mL 5 mL 13

ADMINISTRATION PHASE “CCK Rules”… It is also helpful to have the nurse repeat the physician order (drug name, key word, and mgs) immediately prior to administration of the medications for confirmation… 1 mL 2 mL 3 mL 4 mL 5 mL For error free dosing, always follow the “CCK rules” ! 14

II. Reference Materials a. Preferred Concentrations Click for Detailed Explanations: I. Point of Care Guides POC 1-Resuscitation POC 2-Anaphylaxis POC 3-RSI POC 4-Seizures POC 5-Procedural Sedation POC 6-Antibiotics IV POC 8-Selected Emergencies POC 9-Fluids and Electrolytes POC 10-Burns II. Reference Materials a. Preferred Concentrations b. Calculation Free Product Selection c 1. Drug Doses by Key Word c 2. Drug Doses by Category d. Key Word Safety Nomenclature e. Procedure for verbal orders f. Implementing the System