Identifying human error in the ivf laboratory using electronic witnessing (alpha conference 2012)
Identifying human error in the IVF laboratory using electronic witnessing
Xavier Orriols Brunetti1, Sophie Bird1, Lourdes Muriel Rios1, Shaun Rogers1, Alan Thornhill 1,2
The London Bridge Fertility, Gynaecology and Genetics Centre, London, UK
Department of Biosciences, The University of Kent, Canterbury, UK.
Aim: Electronic witnessing was introduced in IVF laboratories to prevent catastrophic errors
and provide an automated solution to regulatory requirements for double witnessing.
Following validation involving manual witnessing in parallel, an electronic witnessing system
(RI-WitnessTM) has been used continuously for 13 months in our laboratory. We investigated
the incidence of errors and frequency of difficulties encountered while using the system.
Method: RI-WitnessTM uses Radio Frequency Identification (RFID) technology to track
patient samples at each predefined step of the IVF process. Workstations equipped with
RFID readers accompanied by touch screens record every action involving tagged items.
Self-adhesive RFID tags placed on all cultureware destined to contain gametes or embryos
enable readers to register tagged cultureware in any workstation area thereby monitoring
patient identity throughout. Specifically we assessed the (i) true mismatch rate (i.e.
introducing pre-allocated tags to work area whilst mid-procedure involving another patient);
(ii) distribution and duration of mismatches (iii) incidence of additional interventions
required as a consequence of using RI-WitnessTM.
Results: The study period (12/2010-1/2012) involved 1499 patients, 17435 witness steps
and 19880 tags. The total mismatch rate was 51/17435 (0.29%). Excluding 24 flow-chart
related mismatches (including system failures related to initial configuration e.g. cycles
involving donor and recipient) and pre-allocated tags within the frequency range of the
reader but outside of the workstation (6/17435), the true mismatch rate was 0.12%
(21/17435). All true mismatches were rectified in <10 seconds and their distribution was not
confined to specific procedures or times of day. Excluding pre-determined double manual
witnessing steps, only 1% of all electronic witness steps required additional intervention
from a second person.
Conclusion: RI-WitnessTM is reliable and accurately records and time-stamps all laboratory
procedures, identifying a low true mismatch rate (0.12%) which compares favourably with
published error rates of 0.21- 5% for similar laboratory activities.