Introduction: Powered IO needle placement devices have made IO access more readily available during the transport of critically ill children. Appropriate utilization of IO needle access would benefit the patient by decreasing the time required to achieve access and the ability to administer the necessary medications and fluids in an emergent situation. Quality improvement review of the electronic medical records of pediatric transports by Air Evac Lifeteam in 2012 suggested possible overutilization and a high complication rate for powered IO needles when placed by EMS/ED staff versus Air Evac Lifeteam member. Methods: An institutional IRB determined this project did not meet the definitions of human research. A secondary analysis was performed on quality improvement data collected from the electronic medical records of all pediatric (< 12 years of age) transports performed by Air Evac Lifeteam in 2012 in which a powered intraosseus needle (EZ-IO, Vidacare, Shavano, TX) was placed. Patient characteristics (e.g., age, weight, presence of chronic disease, presence of shock, lived or died), intraosseus needle data (e.g., presence of peripheral IV at time of placement), and intraosseus complications (e.g., infiltrated, accidentally dislodged, unsuccessful placement on first attempt) were previously collected onto an EXCEL spreadsheet. Appropriateness of IO needle placement was affirmed if the patient was critically ill (e.g., in shock, requiring ventilatory support) and had insufficient venous access. The patients were divided into two groups based on who placed the IO needle, Air Evac or EMS/ED staff. Non-parametric continuous variables (e.g., age) were compared between the two groups using the Mann-Whitney U test (IBM SPSS, v. 21, Armonk, NY). Nominal variables (e.g., presence vs. absence of complications) were compared between the two groups using chi square test. A p value < 0.05 was considered significant. Results: There were a total of 108 children transported who received at least one powered IO needle, 50 children had an IO placed by Air Evac and 58 children had an IO placed by EMS/ED staff. There were a total of 125 IO needles placed. There was no significant difference in age (median 27 mo, range 0.5 - 151 vs. 24 mo, 0.75 - 151; p = 0.5), weight (13 kg, 2.7 - 80 vs. 13 kg, 3.6 - 60; p = 0.3), primary diagnosis of trauma (23/50, 46% vs. 26/58, 45%; p = 0.9) presence of chronic disease (15/33, 45% vs. 16/40, 40%; p = 0.2), presence of shock (29/50, 58% vs. 24/58, 41%; p = 0.09), or mortality rate (8/50, 16% vs. 8/58, 14%; p = 0.7) between the Air Evac and the EMS/ED groups, respectively. The overall complication rate was 22% (24/108). The complications were failed first attempt (10/24, 42%), infiltration at IO needle site (7/24, 29%), and dislodged needle (7/24, 29%). There was no significant difference in IO complication rate (15/50, 30% vs. 9/58, 16%; p = 0.07) between the Air Evac and EMS/ED groups, respectively. There was a significant difference in presence of a peripheral IV (14/50, 28% vs. 28/58, 48%; p = 0.03) and appropriateness of IO placement (45/50, 90% vs. 42/58, 78%; p = 0.02) between the Air Evac and EMS/ED groups, respectively. Conclusions: Powered IO needle placements were appropriately utilized by pre-hospital providers and ED staff. Complications from powered IO needle placements were high. The medical team must demonstrate adequate knowledge and skilled competency in the procedure of placing and securing a powered IO needle. Quality and safety improvement efforts should focus on periodic simulation training to improve placement and securement of IO needles during transport of critically ill children.