Incorrect gas cylinder was connected and delivered to incubators containing 33 embryos

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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
An incident of this nature has not been previously reported to the regulator (HFEA) therefore it is classified as "very rare".
Time to detection: 
One day
Alerting signals, symptoms, evidence of occurrence: 
33 embryos for eleven patients. Embryos noticed to be growing slowly. Several cases seemed to show development that was a day behind schedule and some degeneration was seen. After investigation it was found that the wrong gas cylinder was connected to the culture incubators.
Demonstration of imputability or root cause: 
Root cause investigation found that the wrong gas cylinder was connected to the culture incubators (helium instead of pre-mixed 5% Oxygen / 6% CO2 / N2).
Imputability grade: 
3 Definite/Certain/Proven
Groups audience: 
Suggest new keywords: 
incorrect gas cylinder
incorrect donor sperm selected
not acting at an alert
Suggest references: 
HFEA state-of-the-fertility-sector- 2018-2019
Evi and Claudia - the key words are incorrect - I cannot change them as they were pulled through from the admin section. Would it be possible for someone with admin permissions to delate them (the key words are showing as: abnormal blood counts', 1st generation, 2nd generation). Thank you, - Done (EP)
Expert comments for publication: 
Incorrect gas cylinder should never have been delivered to the laboratory (believed to have been delivered 1 week prior to connection). The embryologist attaching the cylinder should have checked it was the correct gas. Daily lab checks of active cylinders failed to pick-up that the wrong gas was connected. The two cylinders are the same shape, size and colour and only distinguishable by the small label attached to the collar of the tank.