Utilizing Clinical Microsystems to Improve Mislabeled Specimen Occurrences in the Emergency Department

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Clinical Laboratory Science

Background:

• Mislabeled specimen collection in emergency departments poses significant patient harm risks.
• Improvement initiatives can reduce laboratory specimen rejection and mislabeled specimens.
• A systems approach is crucial for enhancing patient safety in complex healthcare settings.

Purpose of the Study:

• To understand and reduce mislabeled specimen collection in an emergency department.
• To implement and evaluate a quality improvement initiative using a clinical microsystems approach.

Main Methods:

• Utilized the clinical microsystems approach to analyze specimen collection errors.
• Implemented Plan-Do-Study-Act (PDSA) cycles with a clinical microsystems coach.
• Focused on an emergency department within a 133-bed community hospital.

Main Results:

• Achieved statistically significant reductions in mislabeled specimen collection (P < .05).
• Demonstrated sustainable improvements maintained for over three years.
• Initiative began in September 2019 with ongoing positive outcomes.

Conclusions:

• A systems approach, utilizing clinical microsystems, is effective in minimizing mislabeled specimens.
• A persistent, interdisciplinary team is key to creating reliable processes for specimen collection.
• The study highlights the successful application of quality improvement frameworks in an emergency department setting.