Tuesday, November 23, 2010

IVF "lapses"

I must say I was disappointed that the MOH could not bring itself to go beyond just identifying "lapses" as being the causes of the error. Though it's kinda expected. It doesn;t say very much. We all know that accidents are due to lapses.

What we want really to find out is why those lapses occured. Was there a systemic problem that increased likelihood of lapses. Were the quality assurance procedures adequate? Were there previous audit findings that were not remedied? Were weaknesses in the system identified before but left unattended to for too long?

Human error can often be the consequence of systemic failures.


Board Certified Doc said...

Even after stringent Quality checks and entire medical history of the patients, there are still lapses in IVF.

gigamole said...

True. Mistakes are a part of all human activities. That's what proper standard operating procedures (SOPs) are meant to reduce. But that presumes people take SOPs seriously.
If units write SOPs just for the purpose of creating an SOP file, but has no intention of being compliant with the SOPs, that's when 'mistakes' happen.

It is too easy then, to blame the hand holding the pipette and put everything down to 'human lapses'.