ri witness: i'm addicted to you, by carli chapman, reproductive medicine institute
TRANSCRIPT
RI WITNESS
Disclosures
• Advisory Board Good Start Genetics• Advisory Board Serono• KOL speaker for Irvine Scientific
What do you mean?
• A phlebotomist mislabels a blood tube– Patient comes back and has blood redrawn– Patient may be upset
• Clinical personnel report wrong test result– Depending on test result patient may be angry– Patient may leave practice
What do you mean?
• Embryologist makes a mistake with gamete(s)– If reported early the impact can be minimized– Discard gametes prior to fertilization– Contact patient couple(s) immediately– Patients irate/distraught– Probable litigation and bad press
What do you mean?
• Embryologist makes a mistake with embryos– A minimum of two patients are involved but the
number could be as many as 8– Patient gets pregnant with the wrong embryos
and can ruin the lives of all involved– Lawsuit and bad press are a given
How can we minimize risks?
• Procedures that have safe guards built in• Procedures that are followed• Cultivate a culture that understands humans
can make mistakes so that the impact of errors can be minimized by early reporting
• Utilize available technology to protect your practice
IVF Programs
• Culture of safety• Guidelines from SART or HFEA• SOPs• IDC adapted from nursing is often used as a
standard risk reduction strategy
IDC Pitfalls
• Literature from nursing has clearly demonstrated that IDCs rarely have a clearly defined process
• Interruptions and distractions contribute to errors
• High work loads and poor staffing contribute to superficial routine performance of IDC
• Routinely 30% of IDC are not or are poorly performed
IDC Pitfalls
To ERR is human
Key Factors in Human Errors
Conscious AutomaticityInvoluntary Automaticity
Ambiguous AccountabilityStress
IDCs in the ART Laboratory
• IDCs rarely have a clearly defined process• Poor documentation or no documentation of IDC• Electronic medical records make recording IDC
documentation difficult• Interruptions and distractions contribute to poor
patient care• High work loads and poor staffing contribute to
superficial routine performance of IDC
Culture of Safety
• Minimize risk of harm to patients and practices through a system of effective environmental tools and individual performance parameters
• Multiple Strategies• Clearly defined SOPs• Proper staffing to effectively carry out the SOP
How are Gametes ID’d???
Barcodes
Barcoded Sperm
Embryo Bar Codes
Barcodes
• It is only possible to ID the brand and type of package
• Barcodes can only be read one at a time
• Ubiquitous UPC bar-code technology requires contact or line of sight for communication
• CANNOT BE LINKED
RFID Uses
• Chipped your pet with an ID tag• Used EZPass through a toll booth• Paid for gas using a SpeedPass• Transit cards
RFID
• Radio-frequency identification involves the hardware known as interrogators (readers)
• Tags or labels• RFID software or middleware• Passive or Active
Reader• A typical reader is a device that has one or more
antennas that emit radio waves and receive signals back from the tag. The reader then passes the information in digital form to a computer system.
Reader
Tags
• Integrated circuit for storing and processing info
• Antenna for receiving and transmitting
RI Witness
RI Witness
• Give confidence to technicians• Can be customized to your SOPS• Easy to use• Can put technical staff to better use• Creates a document detailing each time a
sample was handled and by whom
Report Example
Why Not?RFID is bad for embryos > No - FDA approved
Expensive > Can lead to savings– Hardware – Consumables
Equipment is cumbersome > Easy to useto use
Makes patients less comfortable with the process > Gives patients peace of (Why are you using that?) mind
RADIO WAVES
Many ART clinic labs have a radio which plays in the laboratory. I believe this is not a good practice. What is the consensus?
Embryomail January 2012
Please clarify your issues with radio play in the laboratory?
a) Music choice may create friction among listeners? b) Music may distract workers? c) Radio waves are disturbing embryos? d) Music is disturbing patients/doctors? e) One of the laboratorians may "bust a move" creating a flash mob?
Wrong Embryo: IVF Mix-up Changes Lives
When IVF Goes Wrong• After she is implanted with embryos belonging to both herself and another couple,
a white woman in New York gives birth to two children, one black and one white. The other couple sought custody of their biological child and won when he was 7 months old. Both couples sued.
• A California woman is implanted with another couple's embryo and gave birth to a baby boy; when he was 10 months old, an anonymous tip prompted authorities to investigate. Eventually the doctor lost his license and paid Buchweitz $1 million in damages.
• A couple sues a fertility clinic for wrongful death after their embryos are accidentally destroyed, and a Chicago judge allows the charge to go forward.
• After Carolyn Savage of Ohio is mistakenly implanted with another couple's embryo, she carries the pregnancy to term and gives the baby to the other couple. Savage and her husband have hired attorneys who are now working on a case against their fertility clinic.
Easy to Use
RI Witness Pitfalls
• Litter • Constant logging in – FOBS allow auto -login• Tags and cards must be ordered from UK –
Supplies can be ordered from Origio/Cooper• Patients lose cards – Eliminated cards from
our process• Alerts interrupt other processes – that’s the
point