Fertility clinic mistakes acid for saline: A 'never event' with lifelong consequences
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The infusion of a scarifying, burn-inducing fluid is definitely a ‘never event.’ The pain of it—to be burned internally and externally—is very traumatic.
—Zane Robinson Wolf, PhD, RN, FAAN
In malpractice discussions, the term “never event” gets used often—sometimes abstractly. This case makes it painfully concrete.
A Pennsylvania fertility clinic recently settled a lawsuit after a patient undergoing a routine infertility procedure was mistakenly injected with a highly caustic acid instead of saline. []
The outcome: second-degree burns, permanent scarring to reproductive organs, and months of uncertainty about future fertility. What stands out in this case isn’t a single egregious mistake—it’s how many small, familiar breakdowns aligned.
The procedure that went wrong
The patient, a 33-year-old woman, went to a fertility clinic in the Philadelphia area in December 2022 for a saline tubal perfusion (STP), a standard diagnostic procedure used to assess fallopian tube patency. []
Instead of saline, 85% trichloroacetic acid (TCA)—a corrosive agent used in gynecology for lesion treatment—was injected into her cervix, uterus, vagina, and fallopian tubes. She reported severe burning pain during the procedure.
“Once the stuff hits the tissue, you can’t fix it,” David Barad, MD, an OB/GYN and reproductive endocrinologist at the Center for Human Reproduction in New York City, told The Philadelphia Inquirer. [] “When you brush it onto tissue, it turns white because it’s basically cooking it.”
Trichloroacetic acid was once used as an herbicide to control grasses that were harmful to crops. [] The US Environmental Protection Agency classifies it as a possible human carcinogen, based on animal experiments. []
“The infusion of a scarifying, burn-inducing fluid is definitely a ‘never event.’ The pain of it—to be burned internally and externally—is very traumatic,” Zane Robinson Wolf, PhD, RN, FAAN, dean emerita at La Salle University’s School of Nursing and Health Science, told The Philadelphia Inquirer. []
Related: A cautious approach or medical negligence? $30 million for botched deliveryHow did this happen?
Court records describe a classic Swiss cheese model of error—multiple system failures aligning:
1. Hazardous chemical stored improperly
TCA, which is not used in fertility procedures, was introduced into the clinic when a nurse practitioner began offering gynecologic services during the pandemic. []
The acid was stored in an unlocked cabinet in an exam room
It was placed alongside routine fertility supplies such as saline
Required hazard signage and safety documentation were absent
This alone violated both clinic policy and OSHA requirements.
2. Supply reuse culture
A single-use device (FemVue) had been pre-filled with fluid from a prior canceled procedure and stored for reuse—a cost-saving practice acknowledged by staff. []
This eliminated a key safety checkpoint: Drawing up fresh saline from a labeled source.
3. Failure to read labels
An ultrasound technician, covering for a colleague, grabbed a bottle assumed to be saline and poured it into a bowl. []
She later testified: “None of this would have happened if I would have just read the label before I poured it.”
That statement oversimplifies the context: Clinicians don’t expect caustic acids to be located next to benign procedural fluids.
4. No verification step
The physician proceeded with the procedure without verifying the solution. Even after noticing an unusual odor, no pause or “time-out” occurred. []
The result? Multiple injections of acid into the patient’s reproductive tract.
The moment of recognition
After the procedure, the patient reported intense burning.[] Only then did the technician check the bottle label. “My stomach hit the floor,” she testified during a deposition.
The clinic attempted immediate saline irrigation and called EMS.[] The patient was transported to a burn unit, where she was treated for extensive internal and external injuries.
Clinical consequences
Second-degree burns to the reproductive organs
External burns to the thighs and legs
Long-term scarring described as “leathery”
Uncertain fertility prognosis for months
Despite this, the patient ultimately conceived via assisted reproduction and delivered a healthy child—a result her physician reportedly called “a miracle.” []
Practical takeaways for the clinic
This case offers uncomfortable but actionable lessons.
Revisit chemical and medication storage. Separate hazardous substances from routine procedural supplies, use locked storage for caustic agents, and ensure clear labeling and hazard communication compliance.
Eliminate informal workarounds. Avoid reusing or pre-prepping single-use devices. Standardize supply preparation immediately before procedures.
Build in forced verification. Require dual confirmation of all injected substances. Open and label solutions in real time, in front of the physician.
Reinforce procedural "time-outs," even in clinical settings. Confirm patient, procedure, and substance, and treat injections like medication administration, not just setup.
Foster a safety culture where assumptions are challenged. Staff should feel empowered to ask to double-check procedures.