From the Department of Obstetrics and Gynecology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont.
J Patient Saf. 2022 Jan 1;18(1):e267-e274. doi: 10.1097/PTS.0000000000000763.
Assisted reproductive technologies (ARTs) are complex processes with multiple and diverse opportunities for human error. Errors in ART are thought to be rare, but can have devastating consequences for patients and their offspring. The objectives of this article are to review known cases of human error in the ART laboratory and suggest preventative strategies.
We performed a systematic review of the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using PubMed and Google Scholar databases. Studies were eligible for inclusion if they involved known cases of unintentional human error in the ART laboratory. Only full-text articles in English were included. References of the resulted studies were considered for inclusion.
A total of 420 articles were screened and 37 articles were selected for inclusion. These largely included case reports and reviews in the medical and legal literature. Twenty-two adverse events due to human error in the ART laboratory were identified. Eight of these adverse events were the result of the insemination with the wrong sperm, 6 errors lead to the transfer of the wrong embryo, 3 lead to an error in preimplantation genetic testing, and 5 adverse events lead to the failure of gamete and embryo cryostorage.
Since the advent of ART, there have been reports of catastrophic events occurring secondary to human error in the laboratory to include incidents of unintended parentage, and have resulted in the loss of embryos and gametes through cryostorage failure. Proposed solutions include the stringent implementation and adherence to safety protocols, adequate laboratory staffing and training, and novel methods for specimen labeling and tracking. Of utmost importance is having knowledge of these errors and the ability to determine cause so that future events can be prevented.
辅助生殖技术（ART）是一个复杂的过程，存在多种人为错误的可能性。人们认为 ART 中的错误很少见，但可能会对患者及其后代造成毁灭性的后果。本文的目的是回顾 ART 实验室中已知的人为错误案例，并提出预防策略。
我们根据系统评价和荟萃分析的首选报告项目，使用 PubMed 和 Google Scholar 数据库进行了系统综述。如果研究涉及 ART 实验室中无意的人为错误的已知案例，则符合纳入标准。仅纳入全文为英文的研究。对所得研究的参考文献进行了纳入考虑。
共筛选出 420 篇文章，其中 37 篇文章被选中纳入。这些研究主要包括医学和法律文献中的案例报告和综述。在 ART 实验室中，共发现 22 起人为错误导致的不良事件。其中 8 起不良事件是由于使用了错误的精子进行授精，6 个错误导致了错误的胚胎转移，3 个错误导致了胚胎植入前遗传学检测错误，5 起不良事件导致配子和胚胎冷冻储存失败。
自 ART 问世以来，已有报道称实验室中的人为错误会导致灾难性事件，包括意外的亲权事件，并导致胚胎和配子通过冷冻储存失败而丢失。建议的解决方案包括严格执行和遵守安全协议、充足的实验室人员配备和培训，以及标本标记和跟踪的新方法。最重要的是要了解这些错误，并能够确定原因，以便防止未来发生类似事件。
