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?

Cause of Error in Paracetamol Toxicity Communication

The primary cause of the error was poor system communication, specifically the lack of proper read-back verification procedures when communicating critical laboratory values, which led to the misinterpretation of the acetaminophen level (213 vs. 2.13) and subsequent failure to initiate life-saving treatment. 1

Communication Error Analysis

The error occurred through a sequence of communication failures:

1. Verbal communication of critical values without verification

   • The technician communicated the result "discontinuously" (saying "two" then pausing, then saying "one three")
   • The nurse misinterpreted this as 2.13 rather than 213 mg/L
   • Neither party used proper read-back procedures to confirm understanding 1

2. Missing safety checks

   • No verification system was in place to confirm critical values before clinical decisions
   • The value of 213 mg/L represents a toxic level requiring immediate N-acetylcysteine treatment according to the Rumack-Matthew nomogram 2
   • The misinterpreted value of 2.13 mg/L was incorrectly deemed normal, resulting in no treatment

Clinical Implications

The consequences of this error were severe:

• Failure to initiate N-acetylcysteine treatment within the critical 8-hour window after ingestion 2
• Development of irreversible liver damage that could have been prevented
• The FDA label clearly states that "acetylcysteine is an antidote for acetaminophen overdose" and "the critical ingestion-treatment interval for maximal protection against severe hepatic injury is between 0 to 8 hours" 2

Prevention Strategies

To prevent similar errors:

• Implement structured communication protocols

  • Use the SBAR (Situation, Background, Assessment, Recommendation) method for all critical value reporting 1
  • Require read-back verification for all critical laboratory values 1

• Improve numerical communication

  • State numbers digit by digit (e.g., "two-one-three" rather than "two" [pause] "one three") 1
  • Document the verification process in the medical record 1

• Establish system safeguards

  • Implement electronic systems that flag abnormal values and require acknowledgment 1
  • Create protocols specifically for acetaminophen toxicity that include verification steps 2
  • Ensure proper training on communication of critical values, especially in pediatric settings where weight-based dosing makes errors more consequential 1

Pediatric-Specific Considerations

Pediatric emergency settings present unique challenges:

• Weight-based medication dosing increases the risk of calculation errors 1
• Hectic environment with frequent interruptions can compromise communication 1
• Critical value thresholds differ between children and adults 1

The American Academy of Pediatrics emphasizes the importance of fostering a culture of safety that encourages error reporting without blame and conducting regular training on communication of critical values 1.