Why do mistakes happen?
Mistakes in healthcare are often a result of error caused by one or more human factors. Human factors such as the ‘dirty dozen’ (Gordon DuPont), can usually be recognized as the root cause of all serious adverse events, often referred to as “never events” in healthcare.
These are lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and involuntary automaticity.
These lead to mistakes in IVF – and we see them more often that we would like where reasons given are ‘staff misread label’, ‘no double check’, ‘patients with same last name’, ‘no traceability evidence’, ‘paper records system’, ‘not following procedures’. All of which ultimately ended in a catastrophic error.
Consequences of error
Errors lead to serious adverse consequences such as complex litigation, financial expense, reputational damage, emotional consequences, ethical consequences.
Frequency of errors
We may like to think that our misidentification rate is very low. But the data shows error happens in over 0.1% of ID checks. In a cycle of IVF there are often between 10 and 50 individual ID checks, so the risk may be higher than you think. In a 700 cycle clinic this equates to about 20 errors per year.
If we add to this further opportunities, particularly with the recent introduction of time-lapse and Pre Genetic Testing (PGT), where material preferentially selected not only has to be identified by patient, but also by individual embryo, the number of individual actions starts to mount up considerably.
What to do about it?
“Introducing automated systems such as barcoding is suggested as an effective way of reducing mistakes caused by human error.”
Ref: Involuntary automaticity: a work-system induced risk to safe health care.
What should an error prevention system offer?
An error prevention and traceability system like Matcher™ should cover every step from when the patient registers with the clinic, all the way through to the end of a cycle with the transfer of embryos, insemination or cryopreservation of material and recording of where each item is stored.
How does an error prevention system reduce risk?
- Introduces forcing functions to staff
- Avoids improvisation and shortcuts
- Fail-safe
- Complete traceability
- Evidence and audit trail
- Ability to link with other systems
- Ability to easily interrogate data
- Time saving
- Instantly accessible, on- and off-site
- Secure
- Paperless
The IMT Matcher™ system
Matcher™ is a reliable and fully validated barcode-based electronic witnessing, labelling, scheduling, and traceability system. It has been specifically created for IVF clinics and donor banks to help prevent errors through misidentification of patients and their gametes and embryos.
Using the Matcher™ system gives fertility centres confidence that they are protecting staff and patients from the risk of mistakes. Gametes and embryos are labelled with integrated barcode and eye readable identifiers, processes are double-checked electronically without the risk of error caused by human factors and working practices are automated and streamlined. And, because the data is captured digitally and in real-time, events relating to witnessing and even products coming into contact with gametes and embryos can be interrogated quickly and accurately providing superior insights for enhanced quality management and root cause analysis.
Conclusion
Despite using verbal and visual checks to ensure patient safety, mistakes can still happen, but with an effective automated system, these risks can be mitigated.
The Matcher™ system offers a barcode technology solution for electronic witnessing, labelling, scheduling and traceability. It also gives the unique benefit of photographic proof in an end-to-end solution with a single point of entry at patient registration and no requirement for a human witness at any point in the chain of custody to help mitigate the risk of human error. No other electronic witnessing solution can offer this.
