Status:
Ready to upload
Record number:
2257
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
An incident of this nature has happened twice now within two years.
Time to detection:
Error was detected when the clinic staff were entering information onto the recipient's electronic records and it was then that the donor mismatch was discovered.
Demonstration of imputability or root cause:
The donor sperm was selected from the latest completed ‘Sperm donor Acceptance form’ which was completed incorrectly at Pre Treatment Appointment (PTA) by the patients and signed as directed by the nurse.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Suggest new keywords:
incorrect donor sperm
Reference attachment:
Suggest references:
HFEA state-of-the-fertility-sector-2018-19
Expert comments for publication:
The nurse was not aware that the patient had previously used two donors, one of which led to a successful treatment and should have been used. The nurse asked the patient to copy the details from the wrong donor sperm acceptance form. The patient however was not aware of the error as the characteristics were almost identical. Copying a previous record was wrong especially as the previous documents being copied were not in date order, so top of the list was not from the previous cycle. The nurse did not have a discussion about the donor sperm to be used and could have interrogated the couple to ensure that the sibling donor sperm was being used.
There was no alert on ideas to show that the Sibling Donor Sperm had been reserved for the couple. Their request and acknowledgement was hidden in an old progress note.