The Tragedy of an Embryo Mix-up

A woman implanted with the wrong embryo highlights the need for automated error-detection systems.
Published: September 29, 2009

Last week, a woman named Carolyn Savage gave birth to a healthy baby boy in Toledo, Ohio. Normally, that’s not big news in the United States, but Savage was carrying the child of Shannon and Paul Morell, who live in Michigan (see Mother in embryo mix-up gives birth).

Savage was implanted with the wrong embryo at a fertility clinic they both shared. The heart-wrenching story could have been even worse, had the two couples not handled the situation with such good grace—the Savages will not fight for custody of the baby, and will hand him over to his biological parents—but the story highlights the problem of human error in critical situations.

Errors like the embryo mix-up are rare, but they do happen. Back in 1998, Donna Fasano, a Caucasian woman from Staten Island, N.Y., was mistakenly implanted with her own embryos and those of an African-American couple, Deborah Perry-Rogers and Robert Rogers, of Teaneck, N.J. She gave birth to two boys, one dark-skinned and one light-skinned. Hospitals have also mixed up blood and organs.

These errors will never be completely eliminated, as there is always some level of human involvement that exposes procedures to human error. But having technology and processes in place to check on human activities in an automated way can reduce errors. Had the embryos been tagged, and had Savage been wearing an RFID bracelet, software could have identified the woman and the embryos, and sounded an alarm. This assumes, of course, that both the embryos and the mother were identified properly in the system, and that the system was set up properly.

Some are skeptical of these systems, but there are advantages in that tags, readers and software don’t get tired and lose focus. They don’t get distracted, lazy or forgetful. One fertility clinic introduced a tracking system two years ago: Overlake Reproductive Health, located in Bellevue, Wash., was the first reproductive-medicine center in the United States to deploy an RFID-based system for tracking human eggs, sperm and embryos. This system helps ensure that no identity mistakes are made during collection, storage and fertilization.

The Obama administration wants to reduce medical costs. One way would be to provide funding for systems that can reduce medical errors, which are costly and, as we see in the case of the Savages, emotionally devastating.

Mark Roberti is the founder and editor of RFID Journal. If you would like to comment on this article, click on the link below. To read more of Mark’s opinions, visit the RFID Journal Blog or click here.