Updates to the IVF mix-up incident

23 Nov 2010

Question No:  618   

Question

Name of the Person: Dr Lam Pin Min

To ask the Minister for Health what is the outcome of the Ministry's investigation into the IVF mix-up incident and what will the Ministry do to reassure patients, both local and foreign, that similar incidents will not happen again in the future.

Reply

Reply From MOH

My Ministry has completed the investigation into the IVF mix-up incident at Thomson Medical Centre (TMC).  The investigators have concluded that the mix-up was due to lapses in procedures and human error.

Assisted Reproduction Centres handle specimens from many couples.  To eliminate the risk of any mix-up, they follow a number of procedures in accordance with international best practices.  First, the embryologist will work on the specimens of only one individual or one couple, at a workstation at a time. Second, he will carefully label all the receptacles and instruments with the couple’s or the individual’s name.  Third, he will discard the disposable instruments such as pipettes, after each use.  This is to avoid any contamination.  Fourth, at every critical step, a second operator will counter-check that the specimens are transferred to the correct receptacles.

The investigators found that the TMC IVF Centre had deviated from some of these procedures.  At the time of the incident, the embryologist was processing semen specimens of two individuals at the same workstation at the same time. The pipette used for transferring the specimen was reused, instead of being discarded after each step.  Even though it was reused only for handling the specimens from the same individual, it unnecessarily raised the risk of human error. This was particularly risky as there was no second person to counter-check that the specimens were transferred to the correct receptacles at every critical stage. These lapses in procedure contributed to the occurrence of a human error, and both led to the IVF mix-up in this case.

Following this incident, my Ministry has directed all Assisted Reproduction Centres to strictly follow the correct procedures, if they have not been doing so.  My Ministry has also suspended the operation of the TMC IVF Centre. 

The incident has no doubt impacted the reputation of the TMC IVF Centre and indirectly affected Singapore’s reputation as a regional medical hub.  TMC has been responsive and has cooperated fully with my Ministry in the investigation.  They are determined to recover from this incident.  The key is full disclosure of the facts and immediate correction of any systemic inadequacies to ensure that similar errors will not recur.  This is the way to regain patients’ confidence and trust.