Catastrophic Human Error in Assisted Reproductive Technologies: A Systematic Review

Area of Science:

• Reproductive Medicine
• Laboratory Science
• Patient Safety

Background:

• Assisted reproductive technologies (ART) involve complex laboratory processes.
• Human error in ART laboratories, though considered rare, can lead to severe consequences for patients and offspring.
• Understanding these errors is crucial for preventing future incidents.

Purpose of the Study:

• To systematically review documented cases of human error in the ART laboratory.
• To identify common types of errors and their causes.
• To propose strategies for error prevention in ART procedures.

Main Methods:

• Systematic literature review following PRISMA guidelines.
• Searched PubMed and Google Scholar databases for relevant studies.
• Included full-text articles in English reporting unintentional human error in ART labs.

Main Results:

• 37 articles were selected from 420 screened, primarily case reports and reviews.
• Identified 22 adverse events attributed to human error.
• Common errors included wrong sperm insemination (8), wrong embryo transfer (6), preimplantation genetic testing errors (3), and cryostorage failures (5).

Conclusions:

• Catastrophic events in ART, such as unintended parentage and gamete/embryo loss, stem from laboratory human error.
• Preventative strategies include strict safety protocol adherence, adequate staffing and training, and improved specimen tracking.
• Knowledge of error types and causes is vital for enhancing ART safety and preventing recurrence.