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6 Steps for Preventing Lab Accidents

Kevin M. Coghlan, M.S., C.I.H.

Laboratories are potentially dangerous work environments, often containing a wide variety of toxic, flammable, corrosive, or reactive compounds. Potentially infectious or pathogenic organisms are handled, and research often involves the use of radioactive isotopes. With the proper training, engineering controls, and administrative precautions, these risks can be effectively managed. However, accidents can and do happen.

There were nearly 10,000 accidents in research laboratories in 2005 injuring nearly 2 out of every 100 researchers, according to government statistics. These accidents were “OSHA Recordable,” meaning that staff injuries required more than simple first aid and that the accidents were attributed to the workplace. Nearly one-half of the accidents resulted in days away from work or restricted work duties.

Accident prevention is imperative for any proactive health and safety program. While unfortunate, accidents do present an opportunity to learn and to improve the performance of a laboratory safety program. The investigation must be carefully and thoughtfully executed to realize the full benefits of an accident investigation program.

The accident investigation and mitigation program involves the following six steps:

1. Notification and Response
2. Site Investigation and Interviews
3. Root Cause Analysis (or similar analysis technique)
4. Report of Findings and Review
5. Implement Corrective Measures
6. Monitoring

1. Notification and Response

The notification and response protocol for any accident must be clearly understood by all staff. Ideally, the supervisor or a committee should lead the investigation. The safety professional’s role should be as a facilitator and guide throughout the accident investigation process. Stakeholder involvement early on is important for acceptance of the findings, and ultimately, of the corrective measures.

Time is critical, and an effective and rapid response will insure that the injured person(s) receives the appropriate medical attention and will not potentially cause injury to others (e.g., in the case of an exposure to an infectious pathogen).

A rapid response shortens the timeframe between the event and the investigation, improving the quality of the data collected during the investigation and interviews. The site must be secured and the accident scene should not be disturbed until the necessary information (e.g., photos) has been collected.

Certain accidents that involve a release of material to the indoor or outdoor environment will require an initial response that may compromise the ability to collect all the necessary information. The need for complete information must be considered in light of the emergent environmental health and safety concerns.

2. Site Investigation and Interviews

The site investigation and interviews with the affected party or witnesses are the core of the accident investigation program. The analysis and ultimately, decisions regarding corrective action will be guided by the data and information gathered during this phase of the accident investigation. Data quality is critical. A uniform approach to conducting both the site investigation and the interviews is essential for consistency. EH&E has developed a laboratory accident investigation data collection tool based on a generic investigation form developed by the National Safety Council.

Obtaining relevant facility information during the site visit is essential. Testing and verification records for safety equipment (e.g., fume hoods, safety showers, eye washes, centrifuges, etc.) can provide clues of potential contributing factors. Product recalls on laboratory equipment may also be an important consideration. Certifications regarding the strain of biological organisms and any attenuating factors (e.g., replication competency) are essential for investigations involving biological agents. Reporting requirements must also be assessed during this phase to determine if federal, state, or local agencies need to be notified.

Speaking with the injured party as close as practical to the time of the event will insure better recall of potentially related or causative factors. The timeframe of the interview has to consider the severity of the injuries: receiving the proper medical attention is the highest priority for the injured party. The interview should be conducted in a neutral environment, and the tone of the interview must be non-confrontational. The accident investigation process is a “fact finding” and not a “fault finding” exercise. It may be necessary to assure an appropriate level of confidentiality to engender the highest level of candor during the interview. The witness must not be led, and the basic questions of who (who was involved? who was present?), what (what procedure was being conducted? What material/equipment was being handled?), where (where did the event occur?), and when (date and time of day?) must be addressed.

Asking open-ended questions will insure that the witness is not led to a particular conclusion and will allow the witness to reflect on the events leading up to the accident. Obtaining corroborating information from other witnesses is valuable for assessing consistency in the accounts. This can be especially challenging in research environments where the native languages of the researchers may differ from each other and/or the investigator. In this situation, it may be necessary to develop a standardized questionnaire in the native language of the witnesses in order to insure an accurate account of the events leading up to the accident.

3. Root Cause Analysis

There are a number of accident investigation techniques, and there is no “right choice” as to which technique to use. Some are more valuable for proactive accident prevention or risk management analysis, such as Failure Mode Effects Analysis (FMEA). Others are better suited for retrospective analysis of events, such as Root Cause Analysis (RCA), which has gained widespread use to investigate accidents. RCA provides a systematic method to trace the cause of an accident back to its source or sources. Often, the source of an accident is multiple “layers” below the observable conditions noted during an interview or the initial site review. The RCA analysis method is often described as “asking the 5 whys.” Although there is no correct number of inquiries, the point is that by asking “why” multiple times to explain an event, the root causes of an accident will be revealed.

For example:

Event: A researcher was stuck with a needle containing a potentially pathogenic organism, requiring treatment with a potent course of antibiotics.

Q1: Why did the researcher get stuck with a needle?
A1: Because the researcher was not careful or familiar with using this device.
Q2: Why was the researcher not familiar with this device?
A2: Because the researcher normally used a single channel pipette to transfer the potentially pathogenic material, but that type of pipette was not available.
Q3: Why was that pipette not available?
A3: Because it was broken and the laboratory manager did not order any more.
Q4: Why did the laboratory manager not order any more?
A4: Because the laboratory manager did not know there were no more working pipettes.
Q5: Why did the laboratory manager not know there were no more working pipettes?
A5: Because the laboratory does not have a system to track equipment.

In this simple illustration, the lack of an equipment tracking program was the source of the accident. If the researchers had working pipettes readily available, this accident would not have occurred. While this is the root cause, there are some contributing factors as well in this example, including training for employees on proper safety procedures (e.g., never use a hypodermic needle to transfer potential pathogenic organisms) and a communication process with the lab manager regarding the need for proper equipment. These must also be considered in order optimize the benefit of any intervention effort. The goal of an RCA is to identify the root causes by better defining what happened, exploring how it happened, and ultimately determining why it happened. Once these questions are answered, corrective measures can be implemented and monitored, preventing similar accidents in the future.

4. Report of Findings and Review

After all the data has been collected and the root causes determined, the results of the investigation need to be communicated in a report to the supervisor of the area in which the accident took place. Again, the purpose of this is to improve safety performance and not assign blame for the accident. Those involved in the accident or who were witnesses should be given an opportunity to review the draft report in order to insure that it accurately reflects their understanding of events. It some cases, or at certain institutions, there may be legal requirements regarding accident reporting. These need to be understood well before the accident process begins. Recent changes to personnel privacy regarding healthcare information may also create barriers to obtaining certain health status information for the accident victim, and appropriate counsel should be sought if it is necessary to obtain personnel health information to inform the accident investigation process.

The reporting of findings and the analysis must be completed rapidly, while attention is still focused on the event. This will allow appropriate time to consider and implement corrective measures and obtain the appropriate level of resources to effect the necessary changes.

5. Implement Corrective Measures

The RCA will identify the root causes and related factors that need to be addressed in order to prevent similar accidents in the future. An implementation plan for corrective measures should be developed shortly after acceptance of the investigation findings. At a minimum, the following should be included in the plan:

  • Scope of the corrective measure
  • Resources needed for implementation
  • Expected outcome
  • Metrics to assess performance.

The scope should be indicated by the RCA, and a determination should be made if the corrective measure is unique to a particular laboratory or department, or if improvements are needed organization-wide. An appropriate level of resources, including staff time, must be allocated to implement the measures, and the expected outcome should be clearly stated (e.g., all personnel will be retrained on how to handle pathogenic material). Lastly, proactive assessment measures should be identified in advance. They must be both practical and meaningful so that performance in this area can be monitored over time.

6. Monitoring

Corrective measures need to be monitored to insure they are being implemented and that they are having the intended effect. Where possible, metrics should be integrated into existing systems (e.g., laboratory inspections or audits) in order to streamline the performance improvement process and to increase the likelihood of acceptance.

Metrics can be process-oriented (e.g., staff completes training program) or results-oriented (e.g., lab inspections document compliance with protective equipment protocols). Both types of metrics are valuable, and often both are necessary. Process-oriented metrics are leading indicators and are valuable if they are closely linked to outcomes. Results-oriented metrics are lagging indicators, although they are very good at assessing ultimate compliance with prescribed outcomes. Accidents are an unfortunate reality in workplaces, including research environments. If the accident is properly investigated, there is an opportunity to improve safety performance. Incorporating these six steps into your accident investigation program will help the investigation team to identify root causes, prescribe appropriate corrective measures, and implement performance metrics to insure a safer workplace.