Brief Pause Between Numbers in Patient Safety, Preventive & Ethics — 32yo Woman | Patient Safety | SMLE Q#989
SMLE Question #989
Patient Safety, Preventive & Ethics
Patient Safety
Last updated: February 2026
A 32-year-old woman presents 6 hours after a large paracetamol overdose. A serum paracetamol level is ordered. Two hours later, the laboratory technician verbally reports the result as “1 … 25” with a brief pause between the numbers. The nurse documents the value as 1.25 mg/L rather than 125 mg/L. Based on the documented value, no antidote is given, and she develops acute liver failure requiring transplant evaluation. In a patient safety analysis, what is the primary error in this scenario?
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