Wrong Embryo Implanted at Milan Hospital Due to 'Human Error'; Lab Suspended

An "error humano" at Milan's San Raffaele Hospital resulted in an embryo being implanted into the wrong patient. At the end of July, a cryopreserved embryo destined for one couple was mistakenly transferred to another woman at the hospital's Medically Assisted Procreation (MAP) center.

The incident led the Milan Ats (Local Health Authority), with the Region's confirmation, to suspend the hospital's Embryology Laboratory activities for fifteen days. The suspension was based on "non-compliance" found during inspections, one of which was conducted jointly with the Ministry of Health.

According to reports, the mix-up occurred when two women were in the waiting room. The patient scheduled to be seen first was mistakenly called second, leading to the transfer being performed on the wrong individual. The error was discovered rapidly; only eight minutes passed before the mistake was realized. Within 24 hours, the woman who received the incorrect embryo was contacted and agreed to an endometrial aspiration to avoid a pregnancy with a biologically unrelated fetus.

The other couple, who were not immediately informed to minimize additional stress, proceeded with a successful transfer of a second, correct embryo. A report from San Raffaele highlighted the "overall vulnerability" of the system following this event. The hospital expressed regret, stating it initiated internal verification procedures two weeks prior upon identifying the "human error" and is implementing corrective measures, such as reorganizing patient entry into the operating room before embryo preparation, to prevent future occurrences. They are also considering implementing an electronic witnessing system for biological sample traceability.