Knowledge claim

Embryo mix-ups have occurred before in IVF treatments.


Require clinics to institute and monitor strong policies and procedures that will lessen the possibility of this happening.


Do such policies and procedures, in fact, exist?

Have such policies been broken and what have been the consequences, if any? (pjt)

Who would do the "requiring" -- state, federal, professional organizations, or..? (pjt)

How do such policies and actual practices vary from state to state; country to country? (pjt)

How often have mix-ups occurred in USA?

In other places? (pjt)

What have been the consequences of mix-ups? (pjt)

How can these mix-ups be prevented in the future? (ss)

Using the following model, the author suggests a double witnessing technique for prevention of embryo mix-ups. This means that there is a primary and secondary operator throughout the IVF procedure. The problems with this are as follows:
1)Too much work is required for the staff. A solution to this is to hire someone simply to double check the work, but this is extremely expensive.
2)Secondary operator is not careful with their job. Risk Analysis can backup this conclusion since the primary is responsible for problem with the procedure.
Another prevention technique employs technology that can assess barcodes. This works 100% of the time. I would recommend this for the company. Even in the event that this does not turn into a major lawsuit, this is important for future safety, and quality of the laboratory.

Reducing risk in the IVF laboratory: implementation of a double witnessing system
Authors: D.R. Brison; M. Hooper; J.D. Critchlow; H.R. Hunter; R. Arnesen; A. Lloyd; G. Horne Source: Clinical Risk, Volume 10, Number 5, 1 September 2004, pp. 176-180
See application of this material in the paragraph 2 of Substantive Report (DRAFT)

(original page by jrc. All italics are mine, signifiying information that I consider is most relevant to the scenario)