Honoring a Legacy While Advancing Pediatric Medication Safety
For decades, length-based systems have helped clinicians rapidly estimate pediatric weight, size equipment appropriately, and reduce cognitive load during some of the most stressful moments in medicine. Dr. James Broselow’s contribution to pediatric safety is undeniable, and his work has saved countless lives worldwide. His legacy deserves both recognition and respect.
Dr. James Broselow was a pediatric emergency physician who fundamentally changed how clinicians around the world approach the care of critically ill children. At a time when pediatric resuscitation was often chaotic, error-prone, and heavily dependent on memory and mental math, he recognized a simple but powerful truth: children are different, and systems needed to adapt to their size, not the other way around. The Broselow Tape translated that insight into a practical, bedside tool that brought order to pediatric emergencies, reduced cognitive load, standardized equipment selection, and improved speed and confidence during resuscitation. Its widespread adoption across EMS systems, emergency departments, and hospitals globally speaks to both the elegance of the concept and the magnitude of its impact. Few individuals have left such a lasting imprint on pediatric emergency care, and Dr. Broselow’s work continues to influence how generations of clinicians think about safety, human factors, and pediatric readiness.
At the same time, pediatric medication safety has been studied extensively over the past two decades, particularly in the EMS environment, where stress, infrequent pediatric exposure, and time pressure converge.
In 2020, the National Association of EMS Physicians (NAEMSP) published a comprehensive position statement and resource document on Medication Dosing Safety for Pediatric Patients in the EMS Setting. This document represents one of the most thorough reviews of the literature on pediatric dosing safety and is widely regarded as a benchmark for best practice.
The findings are clear and consistent.
NAEMSP highlights that pediatric medication dosing errors remain common and clinically significant. Across multiple studies, errors are frequently linked to:
- Weight estimation inaccuracies
- Unit conversion errors (pounds vs kilograms)
- Complex bedside calculations
- Use of static or outdated references
- High-stress, low-frequency pediatric encounters
Importantly, the NAEMSP position statement explicitly concludes that performing medication dose calculations at the patient’s side is an area of very high risk for error and recommends that EMS agencies adopt dose-derivation strategies that avoid real-time calculation altogether.
To mitigate these risks, NAEMSP endorses tools and systems that:
- Provide pre-calculated, weight-based dosing
- Report doses in volumetric units (mL) based on local formulary concentrations
- Are approved by the medical director and aligned with agency protocols
- Can be modified in a timely, system-wide manner as evidence, medications, or concentrations change
- Reduce cognitive load during high-stress pediatric care
This guidance reflects decades of human factors research demonstrating that even experienced clinicians are vulnerable to dosing errors under pressure, especially when mathematical conversions or memory-based dosing are required.
Length-based tools continue to play an important role within this framework. NAEMSP recognizes length-based estimation as a validated and practical method for rapidly determining pediatric weight when scales are unavailable or impractical. Where length-based systems excel is in rapid weight estimation and equipment sizing, functions that remain critical in pediatric emergencies.
However, the evidence also makes clear that static, printed medication dosing references introduce unavoidable limitations. Once printed, they cannot adapt to evolving evidence, guideline updates, formulary changes, or safety corrections. Recent safety alerts involving printed dosing references reinforce this reality, not as a failure of intent, but as a limitation of the medium itself.
In today’s digital era, the direction outlined by NAEMSP represents a natural evolution in patient safety.
The safest systems are increasingly hybrid:
- Length-based tools to rapidly establish size and weight
- Pre-vetted, system-approved digital medication references that deliver dosing without calculation and can be updated as evidence evolves
This approach does not diminish the value of legacy tools. It builds on them.
Progress in medicine does not diminish the pioneers who paved the way. It honors them.
Dr. Broselow gave pediatric emergency care a tool that transformed outcomes and empowered clinicians when children needed them most. Our responsibility now is to carry that legacy forward by continuing to improve the systems we rely on, always with the same goal he had: safer care for kids.
Patient safety is not static.
The evidence isn’t static.
And our systems shouldn’t be either.
Peter Antevy, MD
DISCLAIMER: These links are provided for research and do not have affiliations with Handtevy.