You may have seen the headlines about the crisis at Cleveland’s University Hospitals Fertility Center. It is every safety manager’s nightmare. Between the overnight hours of March 3 and 4, one of the facility’s liquid nitrogen storage tanks began to warm up. Undetected by both the hospital staff and its monitoring system, more than 2,000 embryos and eggs have most likely been compromised during the excursion.
It’s the kind of safety and public relations disaster that should serve as a wake-up call for every clinic and hospital executive. Do you have an automated temperature monitoring system in place that provides 24/7 protection?
Reputation is Everything
The University Hospitals Fertility Center is responsible for helping thousands of women create families, most of whom have had little hope. Tragically, this latest safety oversight has impacted more than 500 patients. “t's absolutely devastating,” said Patti DePompei, President of University Hospital MacDonald Women’s Hospital and Rainbow Babies and Children’s Hospital.
Most unsettling is that the hospital’s freezing tanks have multiple remote monitors and sensors that should have set off alarms and sent alert notifications. Yet even days afterward, the hospital management did not know if the thaw was caused by technical or human error. Now, the affected eggs and embryos must be completely thawed to determine their viability, requiring all patients to contact their physicians for advice on next steps.
Temperature Matters
The mystery about what exactly happened was enough to spark a class action lawsuit filed on March 11. In a statement for the plaintiffs, attorney Mark DiCello said:
Let’s not forget those affected are grieving the loss of thousands of potential daughters and sons. They are in a state of confusion, anger and sorrow, with too many unanswered questions. With this lawsuit, we will get answers and stop this from happening again.
In yet another newspaper story, plaintiff Amber Michalak described her reaction when she got the shocking news: “It’s devastating just thinking the amount of struggle that everyone has to go through. And most of it is not covered by insurance. We paid out of pocket. It’s very expensive.”
The Costs Are High Indeed
Expensive, yes, and not only for the patients. For the hospital, the costs are escalating:
Encouraging Accountability
Perhaps the most important lesson to learn from this unfortunate incident is the importance of accountability. The public wants to know why safety precautions fail. They also want to know how the problem will be corrected. They want answers NOW.
The executive team at University Hospitals has some soul searching to do. If indeed the cause of the excursion was a system failure, they need to make some inquiries:
If the cause of the excursion was human failure, a new set of questions arises:
That the executive staff could not provide a definitive cause several days after the incident is a sure sign of a faulty safety management plan. All the more reason to stay on top of your monitoring system to ensure its viability—and thus the viability of your practice.
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