Status:
Ready to upload
Record number:
1926
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Never reported before
Time to detection:
N/A
Alerting signals, symptoms, evidence of occurrence:
Laboratory staff noticed that eggs and embryos of seven patients being cultured and stored in a specific incubator had failed to progress.
Demonstration of imputability or root cause:
Equipment failure: incubator’s oxygen sensor was faulty, leading not to detect a high concentration of nitrogen and then, resulting a low oxigen concentration ( this should be 5% but was found to be 3%)
Imputability grade:
2 Probable
Groups audience:
Keywords:
Suggest new keywords:
embryos
equipment failure
incubator
oxigen
laboratory
Reference attachment:
Suggest references:
HFEA Adverse incidents in fertility clinics lessons to learn 2013