Investigate a lab-dispatch near miss without mistaking a plausible story for the cause.

Fictional near miss: at 16:02, two sealed lab packages and two route labels were on one work surface. At 16:04, the assembler answered a phone call. At 16:06, package P2 had the wrong courier-route label. At 16:07, the dispatcher caught the mismatch before either package left. The packages are now held for verification. The saved route-directory export and the original label files are available but have not been compared. The team proposes either a one-package-at-a-time workspace or a change to how the route directory is checked. The practice manager can approve a small improvement trial; the dispatcher verifies packages before release. No patient outcome assessment has been performed.