Sir.—The potential for errors in the administration of emergency medications to infants and children is widely recognized. One solution to this problem has been the production of compact guides to appropriate dosages of emergency drugs. One widely marketed product that addresses this need is a slide rule–like device marketed as the EMERGI-DOSE (Emergi-Dose Inc, Holden, Mass). Dosages of pediatric emergency drugs can be found on one side of the device; adult dosages are printed on the reverse side. When one moves the central slide to indicate the appropriate age or weight on the pediatric side (or weight on the adult side), appropriate dosages of emergency drugs appear in transparent windows beside the names of approximately 20 drugs.
The authors wish to warn users of this device that inadvertent reversal of its sliding central portion will cause dangerously inappropriate dosages to appear in the windows on the pediatric side of