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A Scalpel is for Slicing

This story is included in the inaugural 2015 edition of Safety Partners’ publication, “Incidents, Accidents, and Near Misses in Laboratory Research.”

“Oh crap.” Dr. Ming looked down at his gloved hand. He saw a small slice in his left glove. He looked closer and saw a trickle of blood. He looked even closer and saw a small cut.

Dr. Ming was a seasoned scientist working at a medical device company. He was conducting research involving human fecal occult blood. On this day, he was working in the tissue culture room. To be exact, he was slicing human feces with a scalpel to prepare test samples. He was following all the safety procedures: wearing safety glasses, lab gloves, a lab coat, and working with the samples inside a biosafety cabinet.

His scalpel was so sharp and the cut was so small that he didn’t even feel the blade slice his hand. He didn’t know if he cut himself before, during, or after he was slicing the material. It just happened. It was just a tiny, ½ inch cut. But it didn’t matter; he had to respond. The material could contain bloodborne pathogens such as Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV). The company had just conducted their annual required Biosafety and Bloodborne Pathogen training so he knew top-of-mind how to respond and equally as important, why.

He contacted his biosafety officer immediately. As he waited for her to arrive, he removed his left glove using his gloved right hand. He squeezed the cut to draw more blood from the wound.

The company’s biosafety officer, Page, arrived within five minutes. She instructed Dr. Ming to call the local Occupational Health Center in Cambridge, with which the company had an established agreement. Since the incident involved human source material with the potential to harbor bloodborne pathogens, it was the employer’s obligation to make sure Dr. Ming had immediate access to treatment at the employer’s cost. That’s the law. Page even offered to drive him to the Center but he declined and called for an Uber ride.

Even though Dr. Ming had already had his HBV vaccination eight years earlier, the Center inoculated him with vaccine as an extra precaution and put him on a testing protocol. He had to return to the Center at 30, 90, and 180-day intervals to make sure he remained negative for any potential pathogens from the exposure. Unfortunately, there is no faster way to determine if someone has been infected, so it is necessary to wait. By December, six months after the incident, Dr. Ming was given the all-clear. The process was nerve-wracking because he had to wait six months. He thought the odds of infection were low, but it was still stressful. Because of this stress, the Center offered him counseling as part of the treatment protocol, which he declined.

In the end, Dr. Ming was fine, but he lived with the uncertainty of the testing results for six months. Being a very experienced scientist, he remained calm, cool, and collected and he responded “by the book”— the exact response an EHS professional hopes for.

But, the life of an incident does not end there. As a follow-up, Page made an entry on the company’s OSHA 300 Log of work-related injuries and illnesses. It’s a legal requirement. This particular incident was considered recordable and not reportable because hospitalization was not required. But, Page and the company’s Safety Committee did have to record and investigate what happened, the root cause(s), and any remediation.

In this instance, the cause of the incident was determined to be “human error” due to a loss of focus on the task at hand. It was a subtle but important finding that Dr. Ming was distracted while slicing the material. It was June. It was late in the afternoon. His son was in the little league baseball playoffs in Concord. Dr. Ming didn’t want to miss another game. This was yet another case of an experienced scientist in a hurry causing a self-inflicted incident.

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