University Hospitals Fertility Clinic in Ohio said about 950 families were affected by a freezer tank failing, leading to the loss of over 4,000 eggs and embryos.
CNN reports that the hospital was aware that were were some issues with the freezer. Intermittently, a staff member would check on the tank and refill the liquid nitrogen into the tank to keep the freezer at the optimal temperature. This had been going on for weeks before the ultimate failure of the tank.
Ultimately, the tank had failed when there was a steep change in the temperature and the alarm to alert the staff was not active. The alarm, which was put in place in the event of an emergency, has been turned off for some time, it is not clear why it was turned off or for how long. There was no staff on hand at the lab on Saturday evening, the suspected time frame the freezer had stopped working. In the end, there was no staff to respond to the emergency and no way for staff to be alerted of the event, which is where the issue lies. Read more here.
In this instance, you see a few key issues with the way the hospital dealt with the problem. There was no outlined procedure solution to the faulty freezer other than filling up the tank when the nitrogen levels were low. With a good policy and procedure plan in place, you consider all the risks and have an outlined action plan to carry forward. It was also clear that there was a communication issue. The tank’s emergency mechanisms were not double checked and fortified in the event that the temperature rose too high, so the tank never transmitted the emergency alarm to the staff. Since no staff was on hand, another red flag, there was no way to resolve the issue. In such an event, it is important to take extra care to have every staff member aware of the issue, communicate the action plan effectively, and consider all risks.
The execution of proper policy management could have mitigated or eliminated this mistake. Do you think our Healthcare Policy Manager could be right for you? Find out here!