5-year-old Boy in Patient Safety, Preventive & Ethics — 5yo Child | Patient Safety | SMLE Q#1117
SMLE Question #1117
Patient Safety, Preventive & Ethics
Patient Safety
Last updated: February 2026
A 5-year-old boy is brought to the emergency department 6 hours after ingesting a potentially toxic dose of paracetamol. The laboratory telephones the serum paracetamol level and says “two,” pauses, then “one, three.” The value is recorded as 2.13 mg/L instead of 213 mg/L, delaying N-acetylcysteine and the child later develops acute liver failure. Which type of error best explains this event?
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