Overview
- The centre transferred an embryo intended for another couple on 23 July after a biologist read the wrong line in the daily program and selected material for patient B instead of patient A.
- Staff noticed the mix about eight minutes after the transfer and, within 24 hours, clinicians performed an endometrial aspiration on the woman who received the wrong embryo to prevent a mismatched pregnancy.
- Regione Lombardia and ATS Milano ordered a 15-day suspension of the embryology laboratory for inspections; the hospital says it has completed joint checks with ATS and the Centro Nazionale Trapianti and expects to seek reopening in September.
- San Raffaele did not use an electronic 'Witness' sample-tracing system at the time of the error and has announced it will buy one and change workflows so plates are prepared only after the patient is identified.
- Experts point out such mix-ups are very rare—estimated at roughly one per 10,000–12,000 PMA cycles—but say last-minute schedule changes and cascading small mistakes can defeat manual double checks, prompting calls to make electronic tracing part of standard regulation while avoiding undue delays for other patients.