To the Editor We read with interest the Teachable Moment by Himmel et al1 in a recent issue of JAMA Internal Medicine describing the case of a female patient inappropriately treated with hemodialysis for an erroneous value of serum methanol. Although we would agree that ordering appropriate investigations and considering an unexpected laboratory value in the context of the patient’s clinical signs and symptoms are essential to prevent inappropriate patient management and safeguard patient safety, we also wish to express mindful considerations about this case.