Status:
Ready to upload
Record number:
1925
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Never reported before
Time to detection:
N/A
Alerting signals, symptoms, evidence of occurrence:
The liquid nitrogen in the tank run out earlier than expected, leading to loss of 250 donor sperm samples.
Demonstration of imputability or root cause:
The investigation revealed that a valve supplying liquid nitrogen to the storage tank containing the samples had been left closed, preventing liquid nitrogen from entering the system. There was also a damaged connection hose, resulting in the liquid nitrogen evaporating in the hose and emptying the entire supply tank while not filling the storage tank.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Suggest new keywords:
liquid nitrogen
supply
tank
sperm
frozen
semen
loss
Reference attachment:
Suggest references:
HFEA Adverse incidents in fertility clinics lessons to learn 2013
Expert comments for publication:
This incident highlighted the need to make sure that laboratory staff understand how to use the supply tanks and have further training in the use of liquid nitrogen, especially in relation to identifying potential problems.