What was the cause of the error in a child's treatment for a potential paracetamol (Acetaminophen) toxic dose, where the lab result was misinterpreted as a normal level due to poor communication?

Root Cause of Paracetamol Medication Error Leading to Liver Failure

The primary cause of the error was poor communication during the verbal reporting of critical laboratory results, without proper verification or read-back procedures to confirm accurate transmission of information.

Analysis of the Error Chain

The case involves a critical breakdown in communication that led to a catastrophic outcome. Let's analyze the error pathway:

1. Verbal communication failure: The laboratory technician reported the acetaminophen level "discontinuously" (saying "two" then pausing, then saying "one three"), which was misinterpreted 1.

2. Lack of verification: Neither the technician nor the nurse used a read-back procedure to confirm the critical value was correctly understood 1.

3. Decimal point error: The nurse recorded "2.13" instead of "213," a 100-fold difference that misclassified a toxic level as normal 2, 3.

4. Absence of safety checks: No system was in place to verify critical laboratory values before clinical decisions were made 1.

5. Missing follow-up: The error went undetected until the patient developed irreversible liver failure 2.

Communication Failures in Pediatric Settings

Communication errors are particularly dangerous in pediatric emergency settings for several reasons:

• Children require weight-based medication dosing, making calculation errors more common 1, 3
• Pediatric emergency departments are often hectic environments with frequent interruptions 1
• Critical values in pediatrics may have different thresholds than in adults 2
• Verbal orders and communications are common during emergencies, reducing opportunities for double-checks 1

Best Practices to Prevent Similar Errors

For Verbal Communication of Critical Results:

• Implement structured communication protocols such as SBAR (Situation, Background, Assessment, Recommendation) for all critical value reporting 1
• Require read-back verification for all critical laboratory values 1
• Use clear numerical communication: Numbers should be stated digit by digit (e.g., "two-one-three" rather than "two hundred thirteen") 1
• Document the verification process in the medical record 1

For Laboratory Result Management:

• Establish critical value thresholds specific to pediatric patients 2
• Create automated alerts for potentially toxic levels of medications 3
• Implement electronic systems that flag abnormal values and require acknowledgment 1
• Develop clear protocols for management of acetaminophen overdose based on laboratory values 2

For System-Level Improvements:

• Foster a culture of safety that encourages error reporting without blame 1
• Conduct regular training on communication of critical values 1
• Perform systematic reviews of near-misses and actual errors 1
• Implement electronic prescribing systems with decision support for pediatric medication dosing 3

Conclusion on Root Cause

In this case, the evidence points to answer A as the correct choice: "Poor system communication checked what is recorded." The fundamental breakdown occurred in the system for communicating and verifying critical laboratory values, with no mechanism to ensure the accuracy of what was recorded. While the technician and nurse both failed to verify the information (option B), this represents individual failures within a system that lacked proper communication protocols and safeguards for critical values 1.

The case illustrates how a seemingly minor communication error can lead to catastrophic consequences, highlighting the need for robust systems to ensure accurate transmission of critical information in pediatric emergency settings.