CLEVELAND, OH (WOIO) - For three weeks University Hospitals (UH) has been trying to determine what caused a storage tank holding eggs and embryos to malfunction, and why no one caught the mistake.
Originally it was believed 2,000 eggs and embryos were impacted but it now appears the number is closer to 4,000.
When the incident first happened UH outlined four possibilities for the tank malfunctioning and what they were going to investigate:
- The storage tank and its individual components, which include a temperature monitoring system; pressure monitoring system; and, computer software
- Alarm systems
- Security – both physical and cybersecurity
- Liquid nitrogen issues (the tanks use liquid nitrogen)
- Preventive maintenance
In a letter sent to the clients whose eggs and embryos were destroyed, UH explained someone turned off the alarm that would have alerted employees to major changes in the temperatures that protect the specimens.
UH is also explaining that the automated system that adds liquid nitrogen to keep the eggs and embryos at the correct temperature had been malfunctioning for weeks, so they had been manually adding the liquid.
To correct the problem they needed to thaw the tank that was holding the 4,000 specimens. To do that a separate tank was being prepared, but unfortunately the transfer of the eggs had not yet occurred.
At noon today UH posted a video to Facebook of CEO Tom Zenty explaining what they learned.