ABSTRACT
INTRODUCTION: Mislabeled specimen collection in the emergency department has the potential to significantly harm patients. Studies suggest that improvement efforts can reduce specimen rejection from the laboratory and reduce mislabeled specimens in emergency departments and hospital-wide. METHODS: The clinical microsystems approach was used to understand the problem of mislabeled specimens in an emergency department that is part of a 133-bed community hospital in Pennsylvania. Plan-Do-Study-Act cycles were implemented with the help of a clinical microsystems coach. RESULTS: Significant reductions in mislabeled specimen collection were observed over the study period (P < .05). Sustainable improvements were achieved over the >3 years since the improvement initiative began in September 2019. DISCUSSION: Improving patient safety in complex clinical settings requires a systems approach. Using the established framework of clinical microsystems, along with a tenacious and persistent interdisciplinary team, helped create a reliable process for minimizing mislabeled specimens in the emergency department.