Authors: Carolyn Savage
An error by the embryologist of the lab initiated the wrong embryos being pulled and then an insufficient protocol failed to catch the original error in the subsequent five days the embryos grew in the lab before transfer. The initial error by the embryologist in pulling the wrong Embryo Information Sheet was the key misstep, but the fact is this piece of paper was inside a thin file next to the embryos in every step of the five day process, including the procedure room where the embryo transfer took place. In our opinion, those responsible for the mistaken transfer include everyone involved in the process from the moment the wrong Embryo Information Sheet was pulled February 2
nd
through the transfer February 6
th
. Any member of the clinic involved with establishing and monitoring the safety protocols for the clinic is also responsible. The clinic’s protocol was not sufficient and this is evidenced by the fact that the clinic changed its safety protocol on February 16, 2009, the day after the error was discovered.
The change was made too late for us, but fortunately not too late
for future patients. Under the clinic’s new protocol, in the event that two patients have the same last name, the staff affixes a bright orange sticker to the data sheets in the binder to alert personnel. The clinic created a “Patient Verification Form” that has multiple confirmations of patient identification information. Labels on the canes and straws containing the embryos now have five identifiers. The new protocol requires that the staff check all five identifiers before proceeding to the next step. The physician him/herself double checks all identifying information before completing the transfer. Initial documents are cross-checked, not just recently produced documents.
When our clinic discovered this weakness in their protocol, they conducted a review of patient records to be certain that they had made no other mistakes. By doing this, they confirmed that this was the only time that they had transferred the wrong embryos. Thankfully no one else they treated received our fate.
HOW WAS THE MISTAKE DISCOVERED?
Our settlement agreement also required that the clinic describe how the error was discovered. Upon reading the description of the discovery my stomach sank and I had to read it again to make sure I was not mistaken. The explanation is outlined below.
The birth year being incorrect on the labels and Carolyn’s wristband had
nothing
to do with Paul and Shannon’s embryos being transferred to Carolyn. The birth year being incorrect was an independent error. Thus, it took a second mistake to discover the first mistake. Had Carolyn’s year of birth been noted correctly, the wrong embryos would still have been transferred, but the error would not have been discovered on February 15th. The error probably would have gone undetected until Paul and Shannon would have decided to go through with a frozen embryo transfer. At that time the embryologist would have gone to pull their Embryo Information Sheet from the binder and it would have been missing. Likely, he’d then go to the cryopreservation tank and would have discovered that Paul and Shannon’s embryos were missing. We do not know when this discovery would have been made.
I have been told the likelihood of the wrong embryos being transferred is one in three million. What are the chances that an independent error would have been made in conjunction with the same patient that would lead back to the original mistake? This is truly inconceivable.
Carolyn and I struggled with how or if to forgive while we dealt with the impact of the clinic’s actions. Kevin Anderson helped us by introducing the idea of intolerant forgiveness: the ability to forgive the person who committed the error, but not the actual mistake. But while Carolyn was still pregnant, we couldn’t embrace the idea as there was so much else on our minds. After Logan’s birth and our movement into the next phase of acceptance of what had just happened to us,
we focused more attention on how we would deal with the clinic on multiple fronts, including how or if we could ever forgive.
As the legal facilitation process played out, we learned through the mediator that our doctor was visibly distraught. His attorney communicated his deep sorrow for everything surrounding the mistake and the impact it had on our lives. His ongoing struggle with guilt and regret and the sincerity with which he communicated those feelings moved us. Yet our feelings about him were deeply conflicted. All along we knew his expertise and skill brought us Mary Kate when, for more than a decade, everyone else in his field had failed. We felt compassion for his suffering and thankfulness for his expertise with Mary Kate, but we also felt continued anger at him for introducing such a cross to bear in our lives.
We believe in having compassion for those who hurt us. Frequently, we fall short, but we needed to help him and all of those in the clinic to move on from this incident. Just as we had written a letter to him on February 18
th
, we felt compelled to do the same in January 2011.
Dear Doctor,
On numerous occasions we received your messages of deep sorrow and remorse that we understand is shared by several individuals in the clinic. We know these messages are heartfelt and they motivated us to send you this note.
We forgive you and everyone involved in the clinic who is seeking forgiveness. We cannot excuse the act, but we do have compassion for everyone who has to live with this mistake every day. Please release yourself of any guilt and move on with your life. You have much good to do with your career and your family.
Sincerely,
Carolyn and Sean Savage
T
HERE ARE TIMES
in everyone’s lives when they have to make difficult choices. Whether by a fateful accident, or circumstances self-created or brought about by another, somehow you are faced with a choice that you will need to live with for the rest of your life. These types of choices can be wide ranging: from fertility problems, aging parents, medical crises, career crises, marital issues, to parenting challenges. These are moments when the world seems askew. When facing these inconceivable choices, you need as much help and support as you can find. Support can come from your faith, or from those you know and trust, but it can also come from those you have yet to meet.
For us, the defining moment on this journey came on February 16, 2009 when we learned about this inconceivable medical mistake and made the choice not to terminate the pregnancy, nor to fight for custody of Logan after he was born. In the aftermath of those choices, we leaned on our faith, counselors, family, and friends for support. Help also came in a nontraditional manner: Carolyn found a group of women online who had faced infertility problems. Her “Reliable Girls” were spread around the United States and Canada but their support was as constant and immediate as if they were
living around the corner. We also tapped into other online resources to answer our many questions. Our experiences inspired us to build an online community specifically designed to support people who are facing difficult choices. That community is growing right now at inconceivablechoices.com.
We welcome you to this community if you are facing a difficult choice or if you want to provide input and support to other members. We have also invited experts in specific disciplines including counselors, psychologists, psychiatrists, spiritual leaders, and professors to provide advice on issues the community is facing. The various points of view both from these experts as well as other members will benefit members of the community while they are deciding their course of action, as well as support and compassion in the aftermath of their choices.
Our vision for this community is that it will inspire regular people like us to do the right thing, which in turn will benefit our world. We will be at inconceivablechoices.com trying to help and seeking support as well. Please join us.
T
HIS BOOK WOULD
not have been possible without the amazing work of our collaborating writer, Danelle Morton. Danelle, thank you for your countless hours of shaping, editing, and writing! Your insights and keen eye for how to arrange a well-told story have been priceless, and your patience and grace through the challenging moments did not go unnoticed. We are especially grateful for the way you motivated us to write through the most painful of memories. You said we’d be better for it. You were right. We cannot wait to see what you do next, as it seems that everything you touch turns to gold!
We owe a lifetime of gratitude to our literary agent, Linda Loewenthal of the David Black Agency. At a time when we were getting many calls, we had the good fortune of being referred to David, who listened, understood, and knew you’d be the best match for us. We are well aware that you went above and beyond for us throughout the entire process and were always our number one advocate. We have respect for your professionalism and expertise and admire your personal ethic. You are a blessing in our lives.
We knew from the minute we met with our editor Cindy DiTiberio and our entire team at HarperOne that we made an ideal
match! Your insights into what we wanted to accomplish in this book were spot on and your valuable feedback made our story more poignant. Thank you for everything you did in helping us deliver our story to the world.
Thank you to Stephanie Siegel, Esther Zucker and Jackie Levin of NBC. You saw us as people first and a story second. Your professional approach helped us maintain our dignity while sharing our very personal story with the public. You are at the top of your profession.
We would not have been able to endure the challenges of this situation if it had not been for the love and support of our parents. It is the lessons we learned from you as children that shaped our choices of today. We both have talked about the moment when we realized you were not just our parents, but people. And, thankfully for us, you are the best kind of people. We can only hope that when our children are adults they have as much respect and love for us as we do you.
Family is where it all begins and our immediate and extended family is awesome. We are so fortunate to have so many relatives that care about us and support us through actions and prayer. We thank brothers, sisters, brother-in-laws, sister-in-laws, aunts, uncles, cousins and all of those family members who have gone before us. Your support carried us and your prayers lifted us. We will never forget.
This journey deeply challenged us on an emotional level. We would not be “getting through” without the assistance of our therapist, Dr. Kevin Anderson. Kevin, your kind-hearted spirit and ability to reign in our emotions to a place of meaning and respect, have only improved our lives. The lessons of love, compassion, and empathy have enriched us in a way that we could have never imagined.
We will be eternally grateful for the compassionate and top-notch care we received from Dr. Elizabeth Reid and her staff at Premier Women’s Health. We want you all to know that whenever
we entered your office, we knew that you cherished Logan’s life as much as we did. We are positive that he would not be in this world today without your expertise.
We are also grateful to the entire medical team and staff at Mercy St. Vincent Medical Center. You made sure that Logan entered this world safely, and honored our role in his life with humanity. His birth gave us the only moment we will ever have as his mom and dad, and your arrangements provided us with priceless memories. As healers, your care and love brought us dignity and comfort when we needed it most.
In our desperate search for a new fertility clinic and home for our embryos, we were lucky to find Dr. Robert Straub and the entire staff of Reproductive Biology Associates of Atlanta, Georgia. Thank you for taking such good care of us and Jennifer during our time in treatment.
We would also like to thank the faculty and staff of St. Johns Jesuit High School and St. Joseph School, Sylvania, for ministering to our boys throughout this journey. We are so appreciative of the way you kept the boys on track academically and anticipated their emotional needs during a very challenging time. We are truly blessed to have you as partners in educating our children.
Father Joseph Cardone was our first call after learning of our pregnancy with Logan. Fr. Cardone, you helped us calm our fears on a day that we found ourselves in a state of unimaginable shock. We truly appreciate the wisdom you imparted on us and we are also grateful for your ministry throughout our journey. We are lucky to call you a friend.
We had four gifted and caring attorneys that helped us navigate our way through a tangled web of communication, legal precedent, and critical decision making. Mary Smith, your care and concern with our emotional as well as legal well-being was very much appreciated. We couldn’t have prepared for what this pregnancy would bring us without the cool head and valuable insights of
Marty Holmes Sr. Of course, our third call the evening of February 16, 2009, was to our trusted friend, Marty Holmes Jr. Marty you walked this journey with us long past Logan’s delivery as not only a valued attorney but more importantly, a friend. Thank you so much for your compassionate and smart advice, loyalty and support. Lastly, we were blessed to be under the competent care of Brian McKeen of McKeen and Associates. Brian, you cared about us first and the legal case second. You are at the top of your profession, and yet enthusiastically accessible at all times. We admire your strong convictions and the honorable way you advocate for your clients.