New national alert system for IVF clinics
05 June 2003
The HFEA is introducing an Incident Alert System to warn clinics about any incident which could have an adverse effect on patient care and staff safety. It will be the duty of the Person Responsible in each clinic to check their equipment or procedures and take avoiding action so that mistakes are not repeated.
Suzi Leather, HFEA Chair, said:
"The HFEA is there to protect patients and is dedicated to sharing information with clinics, so that we can all learn and clinics can improve their work practices. We hope that the speed of the alert system will reduce incidents happening and all the distress that incurs"
The warning system comes in response to a number of incidents involving either equipment failure or human error. It is clearly impossible to prevent all human error but the alert system will reduce the risk by enabling clinics to change the way they work. The type of incidents that would trigger an alert are:
- Equipment failure such as the freezer malfunction in the Western General Hospital in Edinburgh which led to the destruction of some sperm samples, confirmed 2001
- Human error such as the misreading of patient's name labels on sperm samples which happened at Leeds General Infirmary in the twins mix up case, confirmed 2002
Ends
Notes to editors
The Chair's letter sent out today requires Persons Responsible to ensure that any incident is reported to the HFEA without delay. An adverse incident means anything relating to treatment services which is potentially harmful or actually causes harm to any person, embryos, gametes or staff.
In an average month about five incidents are reported to the HFEA. Typically these relate to equipment failure or breaches of protocol which cause serious concern but haven't done any actual harm.
The Incident Alert System will initially be a pilot scheme from now until September. After feedback from clinics, an improved system will become normal HFEA practice from September 2003.
The Alert will be sent to all 110 licensed centres, HFEA inspectors and professional bodies such as British Fertility Society (BFS) and Association of Clinical Embryologists (ACE).
The HFEA was set up in August 1991 as part of the Human Fertilisation and Embryology Act 1990. The HFEA's principal tasks are to license and monitor clinics that carry out in vitro fertilisation (IVF), donor insemination (DI) and human embryo research. The HFEA also regulates the storage of gametes (eggs and sperm) and embryos.
Page last updated: 12 March 2009