# Embryo transfer error at San Raffaele Hospital > Live situation record from CLSTR: https://clstr.news/situations/embryo-transfer-error-at-san-raffaele-hospital > Updated: 2026-08-31T08:37:33.000Z. Sources: 64. Developments: 3. On July 23, 2026, a medical error occurred at San Raffaele Hospital in Milan during an IVF procedure, resulting in a patient being implanted with an embryo belonging to a different couple. The mistake, attributed to human error involving a biologist misreading the operating schedule or swapping test tubes, was identified eight minutes after the transfer. Following the incident, the couple who received the incorrect embryo consented to an endometrial aspiration to terminate the implantation process. The hospital expressed “deep regret” and acknowledged that the incident revealed an “overall vulnerability” in the system. The second couple involved was notified several days later, a delay the institution stated was intended to minimize emotional stress during their own procedure. In response, the hospital's embryology laboratory was subject to a suspension of activities by the Local Health Authority (ATS) starting August 6, for a minimum of 15 days. San Raffaele has initiated internal investigations alongside the ATS and the National Transplant Center. The hospital is implementing new corrective measures, including electronic tracking, improved identification of biological material, and organizational restructuring. As of August 31, the embryology laboratory has resumed activities. This incident follows a separate event at the same facility approximately one year ago involving frozen oocytes. The error has prompted calls from medical experts, including the president of the Italian Society of Reproduction, for the mandatory implementation of advanced electronic tracking systems, such as ‘Witness’, and clearer regulations defining the responsibilities of gynecologists and biologists. ## Claims - The embryo swap at the San Raffaele center was caused by human error. (corroborated by 5 sources) - The embryology laboratory has been suspended for at least 15 days by health authorities. (corroborated by 5 sources) - The hospital expressed deep regret regarding the incident. (corroborated by 4 sources) - The probability of such an error is estimated at one case per 10,000 to 12,000 assisted reproduction cycles. (corroborated by 4 sources) - The couple who received the incorrect embryo consented to an endometrial aspiration to prevent implantation. (corroborated by 2 sources) - The center is implementing new identification and electronic tracking systems to prevent future errors. (corroborated by 2 sources) - The National Federation of Orders of Biologists called for clearer regulations and defined responsibilities in PMA centers. (single source) ## Timeline ### 2026-08-31: San Raffaele Hospital resumes reproductive medicine activities San Raffaele Hospital in Milan has resumed embryology laboratory activities following a temporary suspension caused by an embryo implantation error in July. 4 sources. https://clstr.news/cluster/san-raffaele-hospital-resumes-reproductive-medicine-activities ### 2026-08-09: San Raffaele Hospital embryo swap triggers investigation in Milan An embryo swap caused by human error at Milan's San Raffaele Hospital has led to a 15-day laboratory suspension and calls for stricter medical regulations in assisted reproduction. 16 sources. https://clstr.news/cluster/san-raffaele-hospital-in-milan-reports-embryo-transfer-error ### 2026-08-07: San Raffaele Hospital confirms embryo implant error in Milan San Raffaele Hospital in Milan suspended IVF laboratory activities following a human error that led to the incorrect embryo being implanted in a patient during a procedure on 23 July 2026. 47 sources. https://clstr.news/cluster/milan-fertility-clinic-halts-ivf-after-wrong-embryo-implantation --- Cite as: Embryo transfer error at San Raffaele Hospital. CLSTR, https://clstr.news/situations/embryo-transfer-error-at-san-raffaele-hospital