Joint Hazard Alert! Action Needed to Address Incorrect Information on the Broselow Rainbow Tape

revised January 22, 2026

Institute for Safe Medication Practices (ISMP)
American Society of Health-System Pharmacists (ASHP)
Pediatric Pharmacy Association (PPA)

The Broselow Rainbow Tape is a height-based measuring tool used during pediatric emergencies that has color zones with precalculated information for medication dosages, equipment sizes, and other procedures. On November 20, 2025, ISMP published an alert¹ receiving multiple reports that the AirLife brand, Revision 3, 36-23446, Print Version Broselow Rainbow Tape contains incorrect dosing information in the calculation basis section. The vecuronium dose is listed as 0.1 mg/mL rather than the correct dose of 0.1 mg/kg, and the flumazenil dose is listed as 0.1 mg/kg rather than the correct dose of 0.01 mg/kg (Figure 1). On December 15, 2025, AirLife notified customers that the tape has been recalled (see attached). Besides incorrect vecuronium and flumazenil doses, the recall notes that the tape lists the intravenous (IV)/intraosseous (IO) ketamine dose for pain/analgesia as 1 mg/kg, whereas the appropriate pediatric analgesic (subdissociative) dose is 0.1 mg/kg. This represents a 10-fold overdose and may result in a dissociative sedation dose being administered when only analgesia was intended.

Organizations should conduct a thorough search and check the inventory in all locations where this product may be used. According to the recall instructions, if impacted product is identified, immediately discontinue use and destroy affected product. Complete the Response Form and Certificate of Destruction Form provided in the recall letter and return the forms to AirLife. There is currently no available replacement product. A revised Broselow Rainbow Tape with corrected information is expected to be available for purchase starting Q2 2026. AirLife will send a notice to customers when such product is available.

Until a replacement product is available, organizations should meet with key stakeholders to discuss risks and determine mitigation strategies. The following may be considered:

• ISMP has heard that some organizations have crossed out the incorrect information and/or added a sticker with the correct dose, which is not without risk. Our organizations do not endorse this practice. However, if this is being considered as a temporary solution, there must be a process to ensure the corrected information is accurate on all tapes and does not cover other important information on the tape. Organizations must also ensure that the ink used to cross out or add corrected information will not be easily smeared, which could also result in practitioners preparing an incorrect dose. Finally, if a sticker with the correct dose is added to cover the incorrect information, the incorrect dose MUST be crossed out prior to application of the sticker. This is to ensure that in the event the sticker falls off, there is still indication that the dose is incorrect.
• Consider alternative products, such as using a well-vetted, commercially available software system or phone application for drug information, such as dosing, preparation instructions, and monitoring.
• Develop organization-specific weight-based emergency medication tables that are immediately available on all pediatric code carts.²

It is imperative that prior to any mitigation strategy is implemented, a failure mode and effects analysis (FMEA) is conducted to proactively identify potential failure modes and devise action plans to close the safety gaps. In addition, disseminate information about this safety concern and the actions you have taken to practitioners and conduct educational sessions as appropriate. Report issues to AirLife, the US Food and Drug Administration (FDA), and ISMP.

Download Recall Notice

References:

1. Institute for Safe Medication Practices (ISMP). Hazard! Broselow Rainbow Tape contains incorrect vecuronium and flumazenil. ISMP Medication Safety Alert! AcuteCare. 2025;30(23):2-3.
2. Institute for Safe Medication Practices (ISMP). Assessing medication safety in settings notdesignated solely for pediatric patients. ISMP Medication Safety Alert! Acute Care.2023;28(12):1-5.