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.
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.
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.
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.