Subscribe to the BioNews newsletter for free

Login
Advanced Search

Search for
BioNews

Like the Progress Educational Trust on Facebook


Multidisciplinary PGD: Redesigning the Patient Pathway


 

Mistakes happen, but the picture is mostly positive

21 July 2014

By Juliet Tizzard

Director of strategy and corporate affairs, Human Fertilisation and Embryology Authority

Appeared in BioNews 763

If our recent report, 'Adverse incidents in fertility clinics: lessons to learn', tells us one thing, it is that mistakes in IVF are rare. Of the 60,000 treatments taking place in fertility clinics in the UK each year, around 500 are associated with an incident, only one of which, on average, is of the most serious ('grade A') kind.

Of course, it would be great if there were no incidents at all, and to patients any number of incidents taking place in fertility clinics must seem too high. But as with all areas of medicine, even with the best intentions and near-perfect systems in place, errors do occur, so it is actually reassuring to know that the most serious mistakes are very rare and the less serious ones are low in number.

This shows us that, in the main, clinics are doing a good job of minimising the number of serious errors. In my experience, clinic staff are highly professional and hold the patient's welfare in the highest regard. Nevertheless, our ambition is to reduce the number of incidents further.

In particular, we think that there remain too many 'grade C' mistakes, such as breaches of confidentiality. As patients have often told us, these mistakes may be less serious at first glance but they can still be very upsetting. Clinics can and should be eradicating these sorts of foreseeable errors by having more effective systems in place and ensuring that staff follow the correct procedures.

So, what can we do as the regulator to reduce the number of incidents? Immediately after the publication of the report, the Authority decided that it would work on a number of fronts to address this issue:

  • being more transparent about the incidents that do happen
  • maintaining the 'no blame' culture and encouraging reporting from clinics; and
  • applying pressure on clinics where necessary.

Transparency

Our report about incidents across the sector will now be an annual one. Producing reports on incidents is a key part of our duty to patients and the public at large. We will also make it clearer on our website how we handle incidents and publish information on this in one place, rather than just in the information associated with individual clinics. Through this approach,we want to promote a culture of openness and information sharing - and show patients that incidents are low in number but, when they do happen, they are well handled.

'No blame' culture

When an incident happens, the most important thing is to learn the lessons from the error made to minimise the chance of it happening again. Our inspectors work with the clinic in each case to understand how the incident happened and can be avoided in the future. Where there is potential for learning, we share this across the sector, whether through an article in our newsletter to clinics (Clinic Focus) or, for more serious issues, through an alert. We will continue this approach.

We are not interested in naming and shaming clinics. Clinic staff are often very upset that a mistake of any kind has been made, because they are professionals who have a genuine desire to help the patient. What's vital here is that we help clinics for the future.

Applying pressure

However, the sector must always be looking to improve, especially in relation to grade C mistakes. Breaches of confidentiality, for example, should be taken more seriously by some clinics and we will be encouraging clinics to up their game in this regard.

We also want them to be more open with patients affected by incidents. These are hard conversations to have - but ultimately, patients respond better to being in the loop and being dealt with in an open and honest manner.

Balance

These approaches - of transparency, a no blame culture and applying pressure - may seem in tension with one another. Obviously, we don't want to overdo it in any area. Too much transparency may encourage clinics to be secretive about mistakes. Overdoing the no blame culture may make clinics think that it's OK to make mistakes again and again. And, applying too much pressure could, again, send clinics into the shadows. These are delicate balances to strike.

However, it's worth remembering that, in the main, fertility professionals working in clinics take incidents seriously. They care about their patients and are upset for them when mistakes happen. We also have a patient population able to understand the complexities in this area, and who are generally happy with the care they receive.

This will stand us in good stead for improving their experience of care even more in the future.

SOURCES & REFERENCES

RELATED ARTICLES FROM THE BIONEWS ARCHIVE

10 October 2016 - by Antony Blackburn-Starza 
The latest data from the Human Fertilisation and Embryology Authority has shown that the number of adverse incidents in UK fertility clinics has increased slightly...
18 April 2016 - by Cait McDonagh 
A clerical mistake at a Sheffield IVF clinic meant that a father's status as his child's legal parent was put in doubt...
21 September 2015 - by Andrew Berkley 
There is no excuse for the administrative incompetence of fertility clinics that has resulted in legal parenthood uncertainty for at least 84 couples, but are medical providers the ideal professionals to seek consent for legal parenthood?...
19 January 2015 - by Professor Eric Blyth and Dr Marilyn Crawshaw 
Freedom of Information requests and email correspondence reveal the HFEA's singular lack of coherence as regards breaches of its family-limit policy...
03 November 2014 - by Nick Jones 
The HFEA will soon modernise its website and redesign Choose a Fertility Clinic - the website's online database enabling patients to access clinics success rates, treatments options and inspection reports. But before we start, we are seeking views on some thorny issues...

14 July 2014 - by Chee Hoe Low 
Hundreds of adverse events occur in UK fertility clinics each year, according to a report from the Human Fertilisation and Embryology Authority...
04 February 2013 - by Ari Haque 
Ottawa fertility doctor Norman Barwin has been suspended from practising medicine for two months after artificially inseminating women with the wrong sperm. Five women were involved in four incidents of receiving the wrong sperm between 1986 and 2007....
28 November 2011 - by Julianna Photopoulos 
Another blunder at IVF Wales in Cardiff destroyed a batch of 'exceptional' eggs only hours after they were donated, leaving a couple devastated...
21 November 2011 - by Dr Lux Fatimathas 
Apologies have been issued by a Welsh IVF clinic following the accidental destruction of three patients' sperm samples. The samples, known as straws, were collected from patients undergoing treatments for blood disorders and cancer that may affect their fertility. An investigation is underway as to why no senior staff were informed when the samples were destroyed in March this year...

HAVE YOUR SAY
Be the first to have your say.

You need to or  to add comments.

By posting a comment you agree to abide by the BioNews terms and conditions


- click here to enquire about using this story.

Published by the Progress Educational Trust


RETHINKING THE ETHICS OF EMBRYO RESEARCH
Genome Editing, 14 Days and Beyond

Public Conference
London
7 December 2016

Speakers include

Professor Magdalena Zernicka-Goetz

Dr Kathy Niakan

Professor Sir Ian Wilmut

Lord George Carey

Baroness Mary Warnock

Dr Simon Fishel

Professor Bruce Whitelaw

Professor Alison Murdoch

Professor David Jones

Professor Sarah Franklin

Professor Stephen Wilkinson

BOOK HERE

Good Fundraising Code
 
Become a Friend of PET HERE and give the Progress Educational Trust a regular donation