How Do We Guard Against Lab Mix-ups?

How Do We Guard Against Mix-ups in the Alta Bates IVF Laboratory?

Several incidents were reported recently in the local and national media on mishaps in IVF programs. These included instances when eggs were inseminated with the wrong sperm, embryos belonging to one couple were transferred into another woman and frozen embryos were improperly labeled and/or could not be accounted for. Such incidents are devastating not only for those directly involved, but are also a source of much anxiety for every IVF patient and fertility care provider alike.

Beyond the initial shock, it is best to learn from such incidents how to implement and refine an identification system eliminating factors that contribute to mix-ups. We think it is important to inform current and prospective patients about the measures taken to assure correct identification of their eggs, sperm and embryos in our laboratory so that they can feel confident that all stepas have been taken to avoid mix-ups.

Egg retrievals take place at the Alta Bates Summit Medical Center operating room. Before admission, each patient is required to show a picture ID and receives a secure wrist band that listing her full name, date of birth, medical record number and the name of her physician. This wrist band is used to identify the patient before and during oocyte retrieval. It ensures that the patient’s identity can be always confirmed even when she is under anesthesia. Every surgical procedure, including oocyte retrieval, is preceded by a “time out” when the surgeon, anesthesiologist, embryologist and OR staff confirm the patient’s identity and the planned procedure.

In advance of the retrieval procedure all the plastic Petri dishes to be used for a given patient are engraved with her name and color coded. A different color is allocated to each patient and each patient’s eggs and embryos are allocated to a different compartment within the incubator. The compartment door is marked with the same color tape and the woman’s name is written on the tape.

The woman’s male partner is required to show a picture ID at the start of semen collection. The specimen container is labeled with his name, his partner’s name, date and time and he is asked to confirm the accuracy of this information. The test tubes and pipettes used for processing semen are color coded and have printed labels that include the names of the woman and her male partner or semen donor.

At any given time, the technician processes only one semen specimen. If there is semen belonging to another patient, it is kept in a separate area in the lab and it is identified by a different color and appropriate labels. While time-consuming and laborious, strict adherence to this system should prevent accidental use of a pipette previously used for another specimen which is what led to fertilization of eggs with the wrong sperm in other programs. Patients, physicians and office staff may have to wait a little longer during busy times to avoid the risk of a mix-up.

We always confirm the identity of a specimen whenever it is picked up regardless of how few or how many patients’ eggs, sperm and embryos are in the laboratory. Her name and color code on the dishes and tubes have to match the paper work. The same identification steps are taken when eggs or embryos are transferred from one petri dish into another.

The nurses and/or doctors inform the laboratory about the names of all patients scheduled for embryo transfer and we adhere to a rigid order of transfer. Transfers of wrong embryos have occurred because of last minute changes in the order in which patients undergo embryo transfer. For that reason the embryologist will ask you to confirm your full name shortly before the transfer takes place even though he or she probably recognizes you and you expect him to know who you are.

The identification of frozen semen and embryos involves multiple levels of duplication (record form, log book, identification cards and computer database record) to ensure that correct specimens can be located at all times. The specimen containers are marked with labels specifically designed for cryo-storage that cannot be smudged during handling in the thawing process. Each cane contains embryos from just one patient.

The above procedures are reviewed and upgraded on an ongoing basis whenever new information and/or technology become available. The combination of well thought-out procedures and our commitment to following them without “cutting any corners” ensures the safety of the reproductive tissues you entrust to our care.