Look-alikes in Lab Test Orders

Introduction. We can use what we learned in the last module to understand the risks of mixing up medications, such as human cognitive limitations. The Swiss Cheese Model of Safety informs us that we should not rely on the vigilance of professionals to catch errors every single time. Instead, we should look for gaps in layers of defenses that may be latent or hidden.

Similar sounding medication names or look-alike lab test orders are known patient safety risks. They are like the holes in slices of Swiss cheese. How would you develop solutions to address such risks? Think about this question when you view the video assignment, which is about an improvement story in a pathology lab. 

Expectations. This is an assigned video and you are required to submit your reflections after watching the video.  Click the video link below to watch. Then click the link “Submit Assignment” ABOVE, to show the submission area. You can write your reflections in a file and then copy and paste, or write directly into the space provided. Do not forget to submit.

Write down your reflection (300 words or less) using this question as a guide:

• What are desired features of effective safety improvement interventions?