Overview
- An internal report says that on July 23 staff at Ospedale San Raffaele mistakenly implanted an embryo belonging to one couple into a different woman after a chain of identification errors was discovered within minutes.
- The woman who received the wrong embryo agreed to an endometrial aspiration 24 hours later to avoid a pregnancy with a genetically unrelated fetus, and the other couple received a correct transfer the same day.
- Agenzia di Tutela della Salute (ATS) Milano and Regione Lombardia suspended the hospital’s embryology laboratory for 15 days after inspections, one conducted with the Ministry of Health, and officials may extend the pause if fixes are judged inadequate.
- San Raffaele says it has completed joint inspections with ATS and the Centro Nazionale Trapianti, applied corrective measures to patient selection and operating-room flow, and is prepared to implement electronic witnessing systems for sample traceability.
- The incident is described as very rare in the literature but highlights how human and process vulnerabilities can allow errors; the centre performs roughly 1,500 embryo transfers a year and professional groups are calling for updated protocols and wider use of tracking technology.