The Health Ministry said that a widely covered mix-up that saw a couple receive the wrong IVF embryo at a Rishon Lezion hospital last September happened because of significant breaches of protocol on the part of staff.
The findings were detailed in a report Wednesday on the circumstances of the incident at Assuta Medical Center, prepared by an external committee appointed to determine what caused the error and to recommend guidelines to prevent similar occurrences..
The committee — led by Prof. Ami Fishman, a leading obstetrician-gynecologist and deputy CEO of Rabin Medical Center and head of its the department of quality and patient safety — also determined that there are two other couples that are likely the genetic parents of the child.
After reviewing medical records and interviewing medical staff and patients, the panel concluded that the mix-up most likely occurred when the woman who received the embryo and the genetic mother were both in the clinic’s waiting area at the same time. The women went in for embryo transfer in the wrong order, resulting in the error.
Another possibility is that a third woman, who was scheduled to undergo embryo implantation around the same time, is the genetic mother. However, the chances of this are lower since this woman had only one embryo transferred, as opposed to the other two who had three.
Six couples who suspect the child may be genetically theirs have sought genetic testing, but that has so far been put on hold by the court.
The committee cited significant breaches of protocol and attributed the error to the entire staff rather than to a single person.
“The committee believes that the embryologists’ workload is the reason for not following proper procedures and ‘skipping’ over steps within the protocols,” the report said.
The report attributed the fact that between 2017 and late 2022, the number of IVF procedures at the hospital increased by tens of percentage points to the government’s shifting fertility treatment to private hospitals such as Assuta. This was financially beneficial for the Health Ministry, private hospitals, and the doctors, but put patients at risk due to the increasing workload.
According to the report, a chain of errors in properly identifying patients and working with embryos pointed to serious lapses in operations, supervision, and management.
“The testimonies before the committee appear to show that Assuta’s patient safety and risk management unit was not involved with the IVF department,” the report said.
As a result, there was no data on mistakes or near-mistakes that may have taken place.
The panel praised the hospital for helping countless infertile couples have babies and start families, but was critical of the placing of financial considerations above quality treatment and patient safety.
“As a result, this medical institution was turned into a factory assembly line, knocked the cart off the rails, and caused great pain and suffering — not only to the patients involved in the immediate circle of this incident but also to the larger community of patients at Assuta and IVF departments around the country,” the report said.
While the committee’s investigation was underway, the Health Ministry demanded in October 2022 that the medical center’s fertility department reduce its operations by 50 percent — from 10,000 fertilization treatments a year to 5,000.
The couple that received the wrong embryo has said it wants to keep the child, born in late October, and is reportedly planning to sue the hospital for $3 million.