[REVISION HISTORY]
Embryo transfer error at San Raffaele Hospital
Updated 4 times since CLSTR started tracking revisions of this situation.
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2026-08-10 20:13 UTC → 2026-08-31 10:17 UTC ·
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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, 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 has been was subject to a suspension of activities by the Local Health Authority (ATS) starting August 6, for at least a minimum of 15 days. San Raffaele has initiated internal investigations alongside the ATS and the National Transplant Center. The hospital is also implementing new corrective measures, including electronic tracking and tracking, improved identification systems. 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, where a technical failure allegedly compromised the ago involving frozen oocytes of twelve couples. oocytes. The error has prompted calls from medical experts and experts, including the National Federation president of the Orders Italian Society of Biologists Reproduction, for clearer regulations and defined responsibilities between gynecologists and biologists, as well as the mandatory implementation of advanced electronic tracking systems, such as ‘Witness’, to prevent similar occurrences. and clearer regulations defining the responsibilities of gynecologists and biologists.
Versions
- 2026-08-31 10:17 UTC Embryo transfer error at San Raffaele Hospital
- 2026-08-10 20:13 UTC Embryo transfer error at San Raffaele Hospital
- 2026-08-10 18:03 UTC Embryo transfer error at San Raffaele Hospital
- 2026-08-10 01:31 UTC Embryo transfer error at San Raffaele Hospital
- 2026-08-09 16:14 UTC Embryo transfer error at San Raffaele Hospital
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