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Security in the Laboratory

All of us in the IVF laboratory take great pride in our work and every attempt is made to set up a system that cannot allow mixing of sperm and eggs between couples. This system is scrutinized internally and by our accrediting agencies during routine inspections with the intention that it should be designed to prevent mistakes entirely. We of course feel that a mistake of this nature cannot happen, but yet we are always looking for ways to make the system even more foolproof. And sometimes, reading about the mistakes of others can be an important part of the process. We always ask, “Could that happen here?”

In this particular case, the answer is a definitive “no”. Our injection procedure is very explicit in requiring a complete change of needle between patients, and also in preventing the needle holder from ever getting touched by any biological material. Unlike practices elsewhere, we have decided that no embryologist at PFC will ever backload a needle with sperm, and instead will work with just one egg and one sperm at a time. Sure, this takes longer, but it’s much safer and prevents any possibility of cross contamination. After we complete a procedure, the microscope and needle holders are stripped down and cleaned before another procedure can be started. And all procedures are witnessed and performed by 2 embryologists as an extra layer of protection. There’s always a second set of eyes on these critical procedures because we don’t want to expose our patients to any risk.

Security measures are everywhere in the IVF laboratory because this is a place where mistakes should not happen. But, we also value the integrity and honesty of our embryologists and I know that if anyone was to make a mistake, they would tell me immediately. One of the first things that new embryologists learn here is that any mistake must be reported as soon as possible and that they will not be fired for owning up to a mistake. This is important, because the sooner a mistake is discovered, the fewer consequences there will be. There was an infamous case a few years ago where a physician in another IVF program knew that he had made a mistake and transferred the wrong embryo to a patient. I have new embryologists study that case because that physician decided to keep the mistake a secret and when it was eventually discovered 2 years later multiple lives and careers were ruined. If that individual had owned up to the mistake immediately, 99% of that damage could have been prevented. Reading the court transcript from that case is sobering for a new embryologist, but it really drives home the importance of honesty and integrity.

We take great pride in our work and if there’s ever a time where we think we could have done better, we will always disclose this information to our patients. We feel good about the culture that we have developed here and we trust the system we have in place for error prevention. It’s an important part of what we do, who we are, and it allows us to go home to our families at night knowing that our work was done well.

- Joe Conaghan, PhD
PFC Laboratory Director

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