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“The Deep Impact of a Near Miss” IANM V7 Story

As we talked about in our January 5th blog It’s Time to Prepare Your OSHA Form 300A, 300A forms summarizing 2022 recordable work-related injuries and illnesses are required to be posted by February 1st. In addition, specific employers must electronically submit 2022 injury and illness data to OSHA by March 2nd.

With all the focus on recordable incidents, it’s easy to forget the importance of documenting near misses. Near miss incidents are important to internally report and record, since follow-up corrective actions can be put in place that prevent actual incidents from happening. 

What is a near miss? A near miss is an incident where no property was damaged and there was no personal injury, but where, given a slight shift in the circumstances, damage and/or injury could have easily occurred.

The following story included in Safety Partners’ publication, “Incidents, Accidents, and Near Misses in Laboratory Research (Volume 7),” highlights the importance of documenting, and following up on, near misses.

I had barely stepped into the lab when I learned about an event that would end up turning my client’s safety culture on its head two years later—quite the way to start the day. The client boss walked up, and we started talking typical morning chitchat. During the conversation, he casually mentioned an incident that I, as the Consulting Safety Officer, had absolutely no knowledge of.

“Oh, I’ve been meaning to tell you, last month we had an incident that we should’ve filled you in on,” the client boss said. I asked him what he was talking about. He told me that extraction kit reagents were poured into the containers for bleached biological waste. Some of the reagents in the kit, such as guanidine thiocyanate, could produce toxic gases when combined with bleach. We’re talking chlorine gas and gaseous cyanide. This stuff is acutely hazardous and can kill you in a single exposure.

Mary, a newly hired Chemical Hygiene Officer, had a reaction to some gas she inhaled while handling the bleached biological waste containers. I asked her, “Did you have symptoms?” She responded, “Yeah.” I followed up with, “Did you call occupational health or the ER?” She shook her head and said, “No.”

I stood there dumbfounded for a second and then got started documenting the incident. Unfortunately, the emergency happened a month ago, so I had to make a retrospective response. Finding out what happened was made more complicated by the time that had passed, which was less than ideal.

After a bit of digging, we found that upon dumping the bleached waste, there was a bright yellow precipitate caked to the bottom of the flask. Bleached biological waste is a consistent waste stream that is usually straw-colored yellow and can go down the drain when fully disinfected. The precipitate was not normal and made no sense. I figured it had to be some kind of reaction that produced it.

We completed the report, and I sent out a memo to everyone explaining what to do with their extraction kit waste. I also added some slides to our safety training slide deck that explicitly explained what the kit was and how to dispose of its waste. That was our response, and the safety committee agreed to it. We figured that was the end of it and moved on.

Shortly thereafter, we moved to a new facility, and things were great. Everyone loved the new, modern space and all its comforts. The company was growing, and the workforce was full of new hires because of the expansion and churn. We’re talking about going from 20 people to 80. Adapting to the growth was challenging, but I did my best to keep everyone safe and regularly alerted the safety committee to keep them in the know.

About a year and a half after the first incident, somebody found an aspiration flask with that same yellow precipitate. Everyone freaked out about this and alerted me, assuming it was serious. The team and I gathered around and took a picture of it. Mary, who was exposed to the gas in the first incident, had been promoted to chemical agent officer and took charge of the response. She was very passionate about it due to her previous experience.

It was at this point that issues in our near-miss reporting process came to light. Mary immediately sent out a memo that escalated the investigation. Normally, we approve this through the safety committee after we complete the response. This time was different; the committee was involved immediately.

This incident was the last straw for management, as the agent was acutely hazardous, and this happened despite training after the first incident. As a result, executive leadership got involved, and it was a whole ordeal.

You see, in the time between these incidents, a board was added, and the company was now publicly traded. Stock value was at stake, and the board was deadly serious about it. Now all these executives in suits were involved and asked, “How did we not address this the first time?” Let me tell you, getting them up to speed was absolutely nerve-racking.

At one point, I got pulled into a meeting about the incident. Much to my surprise, the entire C-suite was there. I got the rest of the safety committee on the phone, and the grilling began. “How dare this happen under our watch?” one of the stern execs asked. Being ever the diplomat, I gently explained that the company had experienced rapid growth and that there were growing pains. I also told them that they could review the safety committee meeting minutes if they wanted to see the trajectory of the changes we’d made along the way.

The minutes showed that we responded immediately to the situation and explained our incident escalation process. In addition, it explained why they hadn’t heard anything about the incident. Turns out, there was no executive looped into the incident response chain of command at the time.

Our incident response was one of the most intense I’d ever led, developing an entirely revamped response protocol before the next safety committee meeting. To start, I got to work creating new training materials, which highlighted this event as an example of how to respond and follow through with incident responses. I made a point in every training session to say, “These are the slides that we actually added to the training in response to this incident.” I also included a picture of the precipitate to highlight that this discovery prompted all these changes, despite there being no exposure.

We also developed a new on-the-job training matrix called Extraction Kit Use Training. Everyone must go through it because everyone uses the kits. We walk every lab employee through all the different waste streams for the extraction kits because there’s a different process for each. The training emphasizes that at no point should they aspirate any chemicals into the bleached waste.

Then, we changed our incident escalation process to make sure that a few of the board members are in regular contact with the safety committee and are informed about every incident, no matter how small. With all the changes we’ve made, it’s now the ideal safety committee.

Now we’re active and responsive; not just reactive but very proactive, too. It surprises me that a near miss would trigger the biggest response I’ve been involved in, but it makes perfect sense. It may have been a near miss, but someone could’ve died. Much better to prevent a casualty than respond to one, and I’m proud of my role in doing so.

For additional information on near miss reporting, or for help creating a near miss incident report form for your organization, please email us at [email protected].

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