Status:
Ready to upload
Record number:
2258
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
An incident of a similar nature took place the previous year.
Time to detection:
This took several weeks (50 days) and was discovered when a member of the nursing staff was preparing the recipient's medical records for her first pregnancy scan (around 7 weeks).
Demonstration of imputability or root cause:
The root cause investigation found when the paperwork was completed to confirm the donor chosen by the couple, based on phenotype (the observable characteristics of the donor), the (coded number) sticker of a different donor was placed on the form in error. This resulted in the incorrect donor being selected by the lab. Eggs were then fertilised with the incorrect donor sperm and an embryo from these was implanted back into the patient which did not have the genetic characteristics that had been originally intended by the couple.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Suggest new keywords:
incorrect donor sperm
Suggest references:
https://www.hfea.gov.uk/about-us/publications/research-and-data/state-of-the-fertility-sector-2019-2020/
Expert comments for publication:
There was no standard operating procedure for selection of sperm donors. Donor identification stickers kept within very close proximity of each other (and in this case were very similar) therefore keep them separate. Review the Phenotype details to ensure there is enough detail to make the differences recognisable to the team. Introduce a second-checking procedure to reduce the likelihood of this incident recurring. A second nurse now witnesses all of the above steps. That nurse also has to sign the phenotype form to confirm that all of the information on there is correct. The investigation team have recommended that further boxes are added to the phenotype sheet for the second checker to sign at each key stage. This is to make the second checking process more active and to reduce the chances of confirmation bias occurring.