Result in Patient Safety, Preventive & Ethics — 6yo Child | Patient Safety | SMLE Q#906
SMLE Question #906
Patient Safety, Preventive & Ethics
Patient Safety
Last updated: February 2026
A 6-year-old boy is brought to the emergency department 3 hours after ingesting a potentially toxic dose of paracetamol. An urgent serum paracetamol level is requested. The laboratory technician phones the nurse with the result, saying “two” (pause) then “one, three.” The nurse documents 2.13 micrograms/mL and relays it to the physician, but the intended result was 213 micrograms/mL. Based on the documented value, N-acetylcysteine is withheld and the child later develops acute liver failure. Which of the following best explains the error that led to this adverse outcome?
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