The field of laboratory safety is very obviously about the protection and well-being of those who work within the labs. The topics of study within this field typically include chemical hygiene, biohazard safety, and even emergency management. One area of focus that historically has not been discussed under the lab safety umbrella, though, is workplace violence. Unfortunately, this topic definitely needs attention and a place among the other safety subjects.
Teaching laboratory staff how to recognize workplace violence (WVP) is important, and the activities that define acts of such aggression are numerous. The National Institute of Occupational Safety & Health (NIOSH) defines WVP as “any violent act, including physical assaults and threats of assault, directed toward team members at work or on duty and include physical injury, threats, abuse, hostility, harassment, discriminatory language/behavior and other forms of verbal violence that can potentially escalate to physical violence.”
The definition is important so staff can identify it, respond to it, and report it. A higher priority, however, is not only to learn the tools that will help staff recognize when potential threats at work arise, but to also be able to de-escalate a tense situations and mitigate any violence altogether. Teach laboratorians to pay attention signs of aggression such as disruptions, outbursts, throwing objects or threatening gestures.
Employees should be taught to respond to growing violence threats by remaining calm, listening, and by demonstrating empathy. Responding to people by yelling or getting into their personal space will only escalate the situation. Your tone of voice, the volume of your voice, your facial expressions and your posture all give signals to the person who is agitated, and if you respond inappropriately with these non-verbal cues, the situation could get worse. Training staff to de-escalate these situations can go a long way toward preventing certain violent incidents before they occur.
Unfortunately, part of the WVP program must be responding to active shooter threats. The Federal Bureau of Investigation (FBI) offers “Run-Hide-Fight” training that helps employees know how to respond when an active shooter situation arises. * There are details in the response that must be considered ahead of an incident. If you can run to an area of safety without getting hurt, go quickly, but do not try to coerce co-workers or patients to come with you. In these situations, you must first consider only your own safety if you wish to survive. If you are in a situation where you can hide in a safe place, be sure to turn off your phone and other electronic devices. Incoming calls can make noises which can alert the shooter to your position. If you must fight, use whatever you can find as a weapon, and fight to win. Do not give the shooter any opportunity to fire his weapon.
The laboratory may follow a facility WVP plan or it may create its own, but there should be a safety plan in place for such situations. Be sure to establish a strategy to identify and address the factors that contribute to violence throughout the workplace. Allow for and ensure prompt and accurate reporting of all incidents of violence including those that involve no physical injury. Empower leaders and employees with the necessary tools to eliminate violence in their areas.
The faster workplace violence can be detected, the sooner a good response may occur. However, as with personal wellness planning, prevention is always a solid approach. Avoiding violent situations altogether can be a part of the lab culture with regular education and training. Make sure there is a strong Workplace Violence Plan in action in your laboratory.
–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.
Wouldn’t it be nice if the samples just magically appeared in the laboratory? Sometimes I wish we had a transporter like in Star Trek that could miraculously produce tubes in the rack already sorted and spun. The reality is, however, that we must rely on others to package and transport samples to the lab. Whether it’s blood, urine, body fluids, or even tissues samples, they make their way from the collection site to the lab. If you work in a hospital setting, samples are delivered to the lab by one of two methods, a pneumatic tube system (PTS), or an internal courier.
Although very convenient when they work, pneumatic tube systems have a few drawbacks. Tube carriers can quickly become an ergonomic safety concern if staff are not properly trained. It is best to limit the number of samples placed in a single tube as overcrowded tubes can be heavy and cause hand and wrist strains if not properly lifted. Sharps such as syringes or needles should never be transported via the PTS. The person opening the tube may not know they are in there and could easily receive a needlestick exposure. It is not a good idea to transport stool or respiratory samples through the PTS either. Specimen containers could open or break inside the tube carrier and give the recipient a not so nice surprise. Additionally, pneumatic tube carriers are known to aerosolize samples. If a spill were to occur, the pneumatic tube system would have to be cleaned or disinfected immediately. Most maintenance or facilities departments have special carriers designed to disinfect the system in the event of a spill. The hardest part may be getting staff to report the spill and initiating the proper cleanup.
2. Some laboratory samples are walked down to the lab. Samples must be in a closed primary container and placed in a clean secondary container, usually a sample transport bag. Often, we see staff who are wearing gloves while walking samples to the lab. When asked, they state that they are carrying stool or COVID specimens and don’t want to contaminate themselves. The outside of the secondary container is considered clean, so there should be no need for gloves. Furthermore, if the gloves or outside of the transport bags are truly contaminated, these staff would be bringing contaminated items through the clean hallways of the facility. Then they would open the door to the lab, which is considered clean, with those same contaminated gloves. The Centers for Disease Control (CDC) has guidelines to mitigate the risk of bringing potentially infectious material into clean areas. The Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings document states that staff must “remove and discard PPE upon completing a task before leaving the patient’s room or care area”1. Another thing to consider is what happens if one of the containers leaks during transport. Or even worse, what if a spill were to occur? Small amounts of blood or body fluid can easily be cleaned with an absorbent and disinfectant. A larger spill, say a 24-hour urine jug, or a hazardous material spill like a tissue sample in a large container filled with formalin, would need more attention. Staff should be trained in how to handle large volume spills and transporters should take precautions, such as using a cart and having a spill kit on hand when moving hazardous material like formalin.
Laboratory staff may not be the ones packaging and shipping samples to the lab, but they are often the recipients and have the responsibility to ensure they themselves and others remain protected. If staff should encounter specimen transport problem situations, be sure they have an effective pathway to communicate and escalate concerns. Often the staff sending specimens are not aware of the risks, so labs should provide that education- they will be thankful for it. Preanalytical processes are at the start of the road toward quality lab results, and everyone involved in each step should keep safe work practices at the forefront.
-Jason P. Nagy, PhD, MLS(ASCP)CM is a Lab Safety Coordinator for Sentara Healthcare, a hospital system with laboratories throughout Virginia and North Carolina. He is an experienced Technical Specialist with a background in biotechnology, molecular biology, clinical labs, and most recently, a focus in laboratory safety.
No one wants to be short-staffed. Cytology programs across the country are either closing or shifting to a Master’s-only degree (to finally reflect our expanded scope of responsibilities), and during the pandemic, it seems there was a mass exodus of retiring baby-boomer cytologists. We’re in a crisis to say the least. As a prominent clinical rotation site, we have no shortage of cytology students. So much that whenever we’ve had an open position in the past, we were confident an eligible student would be able to fill our void. Over the past year, we’ve noticed that students had already secured jobs before they came to us for their clinical rotation. It wasn’t a problem until we realized that we were no longer immune to the nationwide staffing shortage. After one of our cytologists tragically passed away in November of 2022, we made do by working overtime. Before we were able to fill the empty position fifteen months later, another cytologist left to teach. Finally securing an amazing candidate with experience, we knew that we had students rotating through during the winter months, and things started looking up. We encouraged our first student to apply after being blown away by her already-fine-tuned her locator skills and hired her to start as soon as she graduates this summer. We were feeling assured that by the end of the summer (and my supervisor’s retirement), we would be fully staffed, fully trained, and ready to take on the world again. And then, another cytologist let us know she was moving to New England and her last day was five weeks from now. And just last week, another cytologist put in her notice. We’re down 4 cytologists in 15 months, the latter 3 within just 2 months. It’s the highest turnover our department has ever experienced, and our optimism was crushed. Fortunately, we do have more students rotating through this summer, but with 3 positions to fill before August, we’re treading water like our lives depend on it.
Sound familiar? I’m certain that the pervasive staffing shortage is plaguing medical laboratories all over the country. But how do we not let this impact our services? How do we continue to provide the same level of exemplary care while preventing burnout in our team? I’d like to share some lessons learned during our shortage from both a management and cytologist perspective, and I’m eager to hear if you have any you’d like to share from your own experiences.
Lesson #1 – Analyze Service Impact & Develop a Contingency Plan
Will the staffing shortage negatively impact turnaround time? With CLIA’s maximum screening limit of 100 slides in no less than an 8-hour day, a reduction in cytologists shifts the burden of the workload which can risk exceeding limits. Factoring in non-screening activities, such as performing Rapid Onsite Evaluation (ROSE) for FNA procedures, sending out tests for ancillary studies (ThyroSeq, Afirma, HPV, etc.), accessioning, scheduling, slide filing, cleaning biopsy carts, compiling statistics for QA, assisting in the cytoprep lab, maintaining continuing education, etc., it’s far too easy to exceed those limits. We pride ourselves on a one-day turnaround time. Our clinicians and patients expect it, and we refuse to sacrifice that feat. The most significant concern is the rising number of scheduled FNA procedures and not enough people to safely attend them all. We examined productivity and available time for FNAs given the number of cytologists present and daily case/slide workload. First, we looked at the number of slides that need to be screened for the day and divided it by the max mandated screening rate. Then, we counted the number of cases that need to be accessioned and the time involved. This process includes reconciling clinical history and histologic correlation, resolving the plethora of pre-analytical errors (please show us a perfect system for order entry). Considering the time spent on all other activities beyond accessioning and screening including assisting in the cytoprep laboratory, and what remains is the number of hours available for biopsies. We compare this to what has actually been scheduled for the day. Quite often, we are available for much less than what is requested and we must reallocate our resources. Postponing or reallocating out our prep assist duties, filing, and cart cleaning is an option with the cytoprep technicians also working overtime. If and when the prep techs are caught up on their work, they are able to clean carts for us. As for filing slides and paperwork, try to utilize your hospital’s resources, such as volunteers, who are incredibly valuable. Try to also share or reallocate statistics or other QA activities to reduce the burden on one employee while still maintaining operations. You could hire a temporary administrative assistant with a background in medical terminology to assist with accessioning as another option. The worst case scenario would be asking clinicians to “self-collect” FNAs in a balanced salt solution and sending it up to the lab to be processed. Our clinicians value our ROSE services, especially to confirm viability and to ensure we have sufficient material for ancillary studies such as molecular, IHC, and flow cytometry, and not being present would be an ethical dilemma for us all. To help mitigate this, we worked with the schedulers and clinicians across various departments to level out the biopsy schedule, and we postponed or reallocated non-screening activities to be able to handle the FNA workload to the best of our staffing level.
Lesson #2- Go LEAN
Now is a great time to go LEAN, if you haven’t already. And if you think you have, do it again. Analyze your lab for forms of waste. Are there non-value-added activities that are interfering with daily operations? Is your workflow optimized? How much of your cytologist’s time is spent waiting on biopsies? Waiting to call the cytologist to the procedure after the clinician has scrubbed in and marked the targeted lesion could save the cytologist 10-45 minutes of time. By reducing excess and unproductive biopsy wait time, the cytologist can be more productive within the laboratory. You could also reduce motion waste by having one cytologist attend multiple biopsies in the same department within a short time frame. For example, if an ultrasound-guided biopsy is scheduled for 10:15 AM and a CT-scan biopsy is scheduled for 11:00 AM, the same cytologist could attend both without having to return to the lab just to be called back down to radiology. Reducing excess employee movement between departments can also reduce potential care delays by having the cytologist present, moving with the nurses and proceduralist. Similar to the previous lesson on developing a contingency plan with reallocation of resources, how much of the cytologist’s talent is wasted on miscellaneous tasks that outside of the scope of high complexity testing, such as filing, scheduling, and cart cleaning? These are tasks that could be easily assigned to an administrative assistant or prep tech. And lastly, is the lab “over-prepping?” Many hospital laboratories only produce one liquid-based preparation (such as a ThinPrep slide) for morphology and a cell block for ancillary studies. If you are also making cytospins and smears or other additional preparations that offer a higher level of quality than is actually required to make the diagnosis, it could be considered waste. To reduce supply costs and time spent both prepping and interpreting excess material, monitor the laboratory for overproduction and overprocessing waste. This is especially helpful in reducing turnaround time and freeing up existing resources for other tasks.
Lesson #3 – Promote Mental Health & Self-Care
I especially thank my supervisor for this lesson because he and our cytopathology director have always maintained the family-comes-first and quality-of-life philosophies. Recognize that you and your cytologists are humans and not automated machines. Working in a short-staffed state with an abundance of overtime for more than a year can quickly manifest in burnout. You have to protect the gems that you still have. One thing I learned from my supervisor is to continuously seek feedback. How can we prevent burnout and protect both our mental and physical well-being? The main concern was quality of life, which was flourishing when we worked 4-10’s. While the overtime is not mandatory, we had to switch back to a 5-day work week to compensate for the staffing shortage. With that said, the remaining cytologists feel a sense of duty to our patients and therefore have extended their days to 9- to 10-hour days 5 days per week just to cover basic laboratory operations. We anticipate that once our March-start cytologist is fully trained to handle biopsies which run afterhours and our June-start cytologist is fully trained on accessioning, we can return to the 4-10 workweek. But for now, we maintain morale by knowing that the future is bright and we have 3 exceptionally strong senior techs remaining who are fully prepared to train any new hires. While management responsibilities have also shifted during a staffing shortage, a good leader must sharpen their intuition and emotional intelligence, checking in with their employees who are under extreme stress. Too often the manager forgets to check in with themselves while weathering a storm. Remember the airplane oxygen mask metaphor – you must care for yourself before you attempt to help others.Make sure your employees know that too. Patients and their specimens need us, but we cannot provide exceptional services unless we take care of ourselves first.
Lesson #4 – Communicate Intentions & Goals Early & Often
Communication- It’s a two-way street. Please, for everyone involved, consider giving MORE than the minimum required notice. For our department where we clearly do much more than just screening slides and attending FNAs, you must leave enough time to train others on how to handle the processes you own, such as send-out tests or statistics. It is crucial to give the remaining cytologists sufficient time to learn these processes and be able to ask questions while you’re still onsite. Communicating your intent to resign earlier than the minimum required time also enables management to shift their duties and either actively recruit or simply consider prospective candidates to help close the gap. Please also understand that indicating your intent to leave a laboratory does not mean that management will give up on you during your remaining tenure. If anything, leadership will ensure that you are able to accomplish any residual goals within the organization and help you prepare for the next stop on your journey. This principle applies to the entire duration of your career within the laboratory. At the beginning of your tenure, be open and honest about your short-term and long-term goals both career-wise and outside of the workplace so that management can help you customize a plan to achieve those aspirations. Should your goals or intentions change, be transparent. Pivoting is not a form of weakness. While it isn’t easy to brave a storm, especially as the effects of the shortage are exponentially more evident, it’s not only okay to seek help, but strongly encouraged. If you feel overwhelmed or on the verge of burnout, lean on your team members, communicate your concerns to your manager, and take time to ground yourself. Sometimes leaving a laboratory only reduces familiar burnout, and by starting over elsewhere, the unfamiliar may turn out to be more stressful, yet sometimes that new challenge is exactly what you needed. Just keep in mind that the storm will not last forever, and the laboratory sun will shine again.
-Taryn Waraksa-Deutsch, MS, SCT(ASCP)CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.
Managing chemical (hazardous) waste in the laboratory is easily one of the most complicated areas of safety to understand. The regulations are set forth by the Environmental Protection Agency (EPA) and enforced by them or representatives of their state branches. For laboratories that are housed in hospitals or other large facilities, hazardous waste is often removed and handled through other departments like environmental services or maintenance. In the eyes of the EPA, the waste generated by the lab is the responsibility of the lab until it gets to its final disposal location. If other departments manage lab waste, the lab should routinely make sure it is being handled appropriately.
One of the most common areas where hazards occur in waste management regards storage. There are two types of chemical waste storage areas that can be designated in a facility, a Satellite Accumulation Area (SAA) and a Central Accumulation Area (CAA). Chemical waste is initially stored in a SAA which must be within the line of vision from where the waste is generated. Labs may store up to 55 gallons of waste in a SAA, and the EPA does not permit moving waste from one SAA to another. If the waste stored at the SAA is flammable, it should be kept inside of a flammable storage cabinet, but that cabinet would also need to be visible from the point of waste generation.
A second common issue surrounding hazardous waste is container labeling. In most US states, it is required that all containers of chemical waste display the words “hazardous waste.” The label must also show a description of the waste (i.e. stain waste, xylene waste, etc.). Finally, there must be some sort of hazard warning on the label. That warning may be in the form of a pictogram, a NFPA or HMIS warning label. If waste is poured into an empty reagent container, no elements from the original product label may be used, even if the waste is the same as the original reagent. Cross out the original label and place a new complete hazardous waste label on the container.
Containers placed in a SAA should not have an accumulation start date on the container. Facilities are allowed to store waste on site for specific periods of time based on the generator status selected as part of the EPA registration process. However, that storage time limit does not start until the waste is moved to the Central Accumulation Area. All waste in the CAA must be labeled with an accumulation start date.
The third hazard that crops up often in laboratories surrounds recordkeeping. Chemical waste vendors will come to the facility and they may remove waste containers from the CAA or any SAA. When they remove waste, they present a waste manifest which must be signed by a facility representative. Whoever signs that initial manifest must have a specific hazardous waste training that is required by the Department of Transportation (DOT). It is easy for a lab to monitor their own staff training, but if a different department signs waste manifests for lab waste, you need to check that those signing have the required training documentation.
Keep initial waste manifests in a file. The facility should receive final waste manifests within 45 days, and those final copies should be matched up with the initial paperwork so the lab can be sure all waste has been delivered to its final destination point. If the manifest records are kept in other areas of the facility, a lab representative should make routine checks to ensure records are kept up to date.
As you can see, it is fairly easy to make an error when managing hazardous waste for your facility. The regulations are complicated, and we only scratched the surface of them in this blog. Perform waste audits regularly, and include all storage areas and departments in the facility that may handle your waste. Reach out to the EPA or a state branch representative and feel free to ask questions. Managing hazardous chemical waste can be tricky, but it can be done so that the lab follows all regulations and laboratory staff can remain safe.
–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.
On a recent trip to my parents’ house for Thanksgiving, the second-row seat in my wife’s crossover vehicle broke. My wife and I, along with our two daughters were excited to set out for a long holiday weekend, the first in many years. We took that vehicle with three rows of seating so that when we visited my folks, everyone can fit in one car. While on vacation, we returned from a park, and my father exited the second row, followed by my daughter. The lever was flipped in order to fold the seat forward. When the lever was activated again to fold the seat back into its normal position, I noticed the pop-up indicator on the seat did not retract (the indicator lets you know when the seat is locked into place and safe for passengers). After tinkering with the lever, I discovered that the bottom right side of the seat was not locking completely into the floorboard. I immediately thought about the trip home. Our oldest child gets car sick when she rides in the last row, and our youngest’s car seat occupies the other second row seat. Should I take the risk and let my child ride in the semi-broken seat? After all, three out of the four sides were locked in place, and she would only be in danger if we got into an accident. I just had to make sure we drove extra carefully, and nothing would go wrong. The alternative was dealing with a carsick child- a very unpleasant option.
I share this story because I have seen lab staff having to make similar decisions and potentially compromising their safety. I wonder how many of you reading this blog have one piece of broken equipment in your lab that you continue to use. Maybe it is not all the way broken. Perhaps it is just a centrifuge with a broken latch or lock. It might be a drawer with a missing handle, and the drawer falls off the track when you open it all the way. There are worse scenarios. Right now there is someone working in a lab where the biological safety cabinet sash doesn’t go down all the way, and all the chairs have at least one rip in the leather. I know lab chairs are not cheap, and the company that comes out to fit the BSC costs a pretty penny, but how much do you think do you think it would cost if something catastrophic occurred because these issues were not addressed?
Sometimes we don’t think too much about broken equipment until something bad happens. Why would someone continue to use a broken centrifuge? Would you get on a rollercoaster if it were broken? Would you put your child in a seat that was not fully locked into place? I hope not. I sometimes hear managers say they are looking into fixing the issue, or they are waiting to get a quote, but they are still using the broken equipment. We should never be complacent when it comes to safety. Accidents will happen, fires will occur, and people will get injured while working in the lab. We put safeguards in place to reduce these occurrences, but when we choose to work with broken equipment, we negate all of those efforts. If you notice a piece of broken equipment, you need to take it out of service immediately and let your supervisor or manager know. Managers may not be aware of everything that happens in the department, and they depend upon staff to keep them in the loop when equipment gets damaged. Do not encourage working in an unsafe environment.
We made the executive decision to let our daughter ride in the far back row on the trip home. It was raining and we knew there would be a great deal of traffic. My child’s life was on the line, so of course I chose to do the right and safe thing. Did we have to make a few extra stops? We sure did, about three extra stops were included because she felt nauseated. We were actually about 15 minutes from home before she got sick. I knew it would happen; it was just a matter of time. I didn’t mind this time because it beat the alternative of having something happen to her if we were involved in an accident. In life we have to assume the worst will happen so we can make decisions that protect those we care about. It made the trip a little longer, a little messier, but for safety’s sake we have to be willing to take the long road, work a little harder, and maybe even be inconvenienced at times. Lab life isn’t always easy either, but it is worth the effort to protect those in our department. We should always take on the work to make sure the patients, our coworkers, ourselves, and even our loved ones are always as safe as possible.
-Jason P. Nagy, PhD, MLS(ASCP)CM is a Lab Safety Coordinator for Sentara Healthcare, a hospital system with laboratories throughout Virginia and North Carolina. He is an experienced Technical Specialist with a background in biotechnology, molecular biology, clinical labs, and most recently, a focus in laboratory safety.
Whether you are a newly graduated scientist or a seasoned individual starting at your fifth lab in your career, you might be surprised by the safety culture at the new facility. You could be so impressed by the safety culture at your new laboratory that you question how no one was seriously hurt at your former one. Or you could walk into the lab on your first day and immediately get a bad feeling in your gut. No matter how you feel on day one, two, or maybe day 32, just know that there are some things you can do to help understand your new perception of the culture. Any great piece of research starts with a question or two. Let’s examine some queries that can help you wrap your head around why some labs win, and others fall short when it comes to their safety culture.
First, let’s start with the why. When the safety culture does not look good, it is easy to assume that the deviant behaviors you witness are simply people taking advantage of the system. But not all bad behaviors are spawned from a desire to do harm. You need to find out what is influencing their unsafe behaviors. Most of the time, subpar safety behavior stems from a lack of understanding the consequences of unsafe actions. For example, some folks may not realize that handling their cell phone with gloved hands in the lab has the potential to transfer pathogens into the breakroom when they place that same phone on the table when they are eating their lunch. When the timing is right, you should have a conversation with the employee about what you saw and inquire if they are aware of the potential safety risks. You never know, you could discover that it was a topic skipped in safety training and you single-handedly just improved the quality of your safety training program!
The next question you should ask yourself is, are laboratory leadership aware of the safety issues present in their lab(s)? In most labs, the managers are often overburdened, spending most of their time chasing a schedule, trying to fill open positions, or putting out fires (figuratively we hope). Therefore, you should not assume that leadership is aware and allow unsafe practices to occur in the lab. Sometimes managers and supervisors are so hyper-focused on one thing, they might not be able to see a safety issue right in front of them. If you see unsafe habits, bring it up to lab leadership and share with them that your intentions are to avoid a potential harmful event from occurring. In some cases, managers are already aware of the situation and are trying to come up with solutions. Your conversation with them and perspectives about the safety concerns might be the missing piece that helps complete the puzzle they are trying to solve. So, you should feel comfortable bringing your concerns and be prepared to come with solutions to any problems you present to them.
Finally, ask yourself if the safety issues you see are isolated to a particular shift or certain individuals. Although it is the responsibility of laboratory leadership to champion the safety culture, it is up to the staff to feed and nurture its existence. When everyone works together, it is reflected positively in the safety culture, the audit results, and the injury and exposure reports. When gaps are present, there will be an increase in the negative indicators until the issues are identified and resolved. Instead of making assumptions about the safety culture of the entire lab, try to see where the gaps exist and then revisit the first question- why? It is a lot easier to coach a single individual that wears earbuds in the lab than the entire night shift crew that refuses to wear a lab coat until 5 minutes before the day shift supervisor appears. If that single person is the root of your safety concerns, don’t let their behavior go unchecked. As with negative attitudes in the department, poor safety habits can spread like wildfire. If a single individual’s behavior is not addressed, then others will soon follow suit. They will see that there are no repercussions to lax safety behaviors or worse, they will think nothing bad can come of cutting safety corners. Laboratory leaders and coworkers that normalize poor safety habits are only making the situation worse and damaging the safety culture of the lab while putting the entire staff at risk.
You should never assume a safety culture persists on its own. A good or bad safety culture is the sum of many different factors, and the reason behind the factors can be vast. So, before you are ready to write off a lab as unsafe, take the time to dig a bit deeper and find out what contributed to making the safety culture what it is today. If the lab has a great safety culture, find out why. The lab you are in today may not be the place at which you retire. Your path might lead to a different workplace that has an even worse safety culture than the one you left behind. By asking questions about what creates a great safety culture, you become equipped with the right tools and knowledge and will then be in a strong position to use what you know to improve the lives of others in your new lab.
-Jason P. Nagy, PhD, MLS(ASCP)CM is a Lab Safety Coordinator for Sentara Healthcare, a hospital system with laboratories throughout Virginia and North Carolina. He is an experienced Technical Specialist with a background in biotechnology, molecular biology, clinical labs, and most recently, a focus in laboratory safety.
Microaggression is a term first coined by Dr. Chester Pierce, a Harvard psychiatrist, in 1970, where he described the lived experiences of an African American man navigating in white predominant spaces. It took 37 years for the term microaggression to come into mainstream acceptance when it was re-introduced by Dr. Derald Sue in 2007, where he expanded the definition to include general disrespect, devaluation, and the exclusion of minorities.
I still remember my first frozen on-call as a PGY-1 AP/CP resident; I came to work at 6am to prep the gross lab. I was told to fill the big formalin container for the day ahead, log all the refrigerated patient specimens from overnight surgeries, ink to orient and then cut the specimens so they can be fixed. Then finally when I moved to change the water in the stain line, suddenly the tech walked in and asked, “Are you Muslim?” I paused and froze for a moment, didn’t have any words to answer his question. Then I said, “No!”, and he walked away. This incident set me back the whole day, because I was replaying it in my mind again and again, to see why he had asked this specific question to me. Maybe I should have answered differently. I didn’t know of the term, “microaggression” back in 2009.
Now I am equipped with this term and training my colleagues to respond in real-time to these types of instances, I wonder how empowered I would have been if I knew about microaggressions from med school/residency training. I would have been more confident in my interactions, rather than walking on eggshells.
When teaching bystander intervention, there are multiple mnemonics, so that you can quickly react to the situation rather than lack of response in the moment. The 5D’s from American Psychology Association that calls to action are: Distract, Delegate, Document, Delay and Direct. In JAMA Surgery, Dr. Nafisseh Warner introduced GRIT (Gather, Restate, Inquire, Talk It Out). In a learning environment to shift the power dynamics to the clinical learner, the visual below from Dr. Justin Bullock is helpful in breaking down each segment of bystander response: pre-brief, during and after the microaggression.
Reference: Bullock JL, O’Brien MT, Minhas PK, Fernandez A, Lupton KL, Hauer KE. No One Size Fits All: A Qualitative Study of Clerkship Medical Students’ Perceptions of Ideal Supervisor Responses to Microaggressions. Acad Med. 2021;96(11S):S71-S80.
When trainees come into laboratory spaces, it is essential to conduct a pre-briefsession to create a safe-learning environment. During orientation, talk to learners about the possibility of racism and bias. In medicine, the hierarchy is engrained and overemphasized within the system, so learners are hesitant to respond to microaggressions, report bias and racism. Therefore, taking the time to pre-brief will shift the power to learners to say something when being the target of racism and bias.
During microaggression, recognize and analyze it. Is it objectifying? Is it prejudice or negative attitude/stereotype? The usual response to microaggression is no response because you freeze, like I did in my scenario. The effective response is short and direct, most importantly respond in real-time. The degree of response will vary according to the situation and learner’s preference, sometimes the supervisor may bear witness or stop the interaction to create an opportunity for the trainee to exit.
After the microaggression, do not ignore what happened and move on. Supervisors should take the time to privately check-in with the learner and offer support, which is the most preferred approach. Team debriefs might invite an exhausting dialogue and may cause the target to relive the traumatic experience. Also, if there are instances of repeat microaggressions, propose the option for re-assignment.
To create a safe learning environment for our learners it is essential to prioritize psychological safety in our busy clinical services. Taking the time to pre-brief with learners, check-in and offer support to the target will promote a better work culture. Together we can support and empower each other to mitigate microaggressions at our workplaces.
-Deepti Reddi, MD, Assistant Professor of Pathology, Department of Laboratory Medicine and Pathology, UW School of Medicine; UW Medicine’s equity, diversity, and inclusion (EDI) peer trainer at the Office of Healthcare Equity (OHCE) and teaches Racism & Bias for Center for Learning & Innovation in Medical Education (CLIME) in Advanced Clinical Teaching Certificate program. She is also a 2021 ASCP 40 Under Forty Honoree.
One of my favorite scary movies is the original Fright Night, a campy horror film from the 1980s. In it, the main character, Charlie, discovers he is living next door to a vampire. He realizes there is danger, so the first thing he does is research. He asks his friend “Evil Ed” about vampire knowledge and tries to get as much information as possible. He performs a risk assessment in his home and then puts into place some engineering controls (crosses, wooden stakes, windows nailed shut), some PPE (a garlic necklace), and even work practice controls (do not invite a vampire into your home). Charlie also utilizes help in the form of an out-of-work actor who starred in cheesy vampire flicks. These actions taken by Charlie make sense: he takes the time to learn about the danger, and then he prepares to deal with it safely.
As a lab safety professional, I often wonder why people who work in the laboratory do not follow the same pathway. They are educated in school and in training about the multiple dangers in the department, but many work throughout their lab careers utilizing unsafe practices. For example, it is common for staff in a histology lab to work with or near sharp blades in cryostats and microtomes without using any implements or safety guards. The number of reported cuts that repeatedly occur in these labs is shockingly high, and the number of unreported injuries is likely much higher. What is interesting is that when having conversations with those laboratorians, they are fine with accepting the risk and accepting the injuries or exposures when they occur.
The concept is the same, isn’t it? Vampire teeth can kill you, so you protect yourself. Bloodborne pathogens and sharps can also be deadly, but why isn’t there concern about the use of safe lab practices with blades? There may be a few reasons.
The use of large, sharp blades is, of course, common in histology labs. They are a part of the everyday job. Hands go near them when tissue is cut, when tissue blocks are changed, when moving the blade, and when changing the blade. In some busy cutting labs, a microtome blade can be changed up to twenty times a shift. This ubiquitousness of this item tends to create a sense of complacency about it. Yes, people have been injured, some badly, some amputations have even occurred, but in comparison to the number of tissue blocks cut, those reported injuries may seem like small numbers…unless it happened to you.
Another reason for complacency is that often, when blade injuries occur, the blade has been used with fixed (and essentially harmless) embedded tissue or when they haven’t been used at all. Many cuts are “clean” and minor, so there is no true perception of danger.
A third reason I have often heard about why blades are handled with no safety measures in place is that productivity in the lab is key. There are standards about how many tissue sections should be made during a standard shift, and using implements to move or change the blade would hinder those goals. Read that again- productivity, in the minds of some, is more important than staff safety – and that is an acceptable stance for them.
As a lab safety professional, one of my goals is to change that unsafe mindset. It does not matter in which section of the laboratory work is performed, staff should be made aware of the risks, and they should be taught how to utilize engineering controls, administrative controls, and PPE to avoid the hazards in the department. Then there should be ongoing management of the safety program which includes risk assessments, safety audits, and follow up when injuries or exposures do occur.
Train those who work with blades in the department. Show them how to work with and handle them safely by using magnet-tipped brushes and rubber-tipped forceps to change and move them. Teach them to always engage the blade guards when hands go anywhere near the blade. Talk about serious cuts and amputations that can occur when unsafe practices are utilized. Review work practices regularly to ensure staff remain safe each time they use the equipment associated with the blades. With sharp blades, the danger has already been invited into the lab. Take the next best precautions you need to make sure your blade doesn’t bite and become a “fright knife.”
–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.
A delivery truck is backing up to the loading dock of an empty warehouse. You are about to receive the first ever delivery from your supplier, and soon this new lab will be up and running. Are you going to unload the truck and stash the new chemicals in the corner? I hope not. Getting started with chemical management can be a little overwhelming, but it certainly can be done. Benjamin Franklin said, “By failing to prepare, you are preparing to fail.” It is best to start with a plan, preferably a chemical hygiene plan (CHP). So, let’s take a dip into a few important sections of the CHP.
The creation of a great CHP begins by listing the chemicals you have onsite and their associated hazards, and this will be your chemical inventory. Categorizing your chemicals by hazard type helps you to determine where and how they should be stored and handled once in the lab. It’s important to determine the compatibility of your chemicals before you place them on the shelves. Storing your inventory in alphabetical order may make it easier for staff to locate a particular item, but not all chemicals play nice with each other when they are neighbors. A bottle of chloric acid stored next to calcium hydroxide could be an accident waiting to happen. Make sure incompatible chemicals are kept apart, stored on separate shelves, or kept in separate bins. Do you store ethanol onsite? What about xylene? Both are flammable chemicals, so you may be able to store them in the same flammable safety cabinet. Separate corrosive storage cabinets may also be needed for your strong acids and bases.
Now that we have the chemicals separated, what do you do when it is time to use them? Your CHP should outline training and personal protective equipment (PPE) requirements for the different hazards as well as any engineering controls required to ensure work can be performed safely. Do you have a biological safety cabinet (BSC) in your lab? Be careful, not all BSCs can or should be used as a chemical fume hood (CFH). A CFH is designed with specialized filters and/or ducting to eliminate hazardous vapors that BSCs lack. Only a few classes of BSCs can provide protection from volatile chemical fumes. Check with the manufacturer to determine if it is safe to handle volatile chemicals in your BSC.
Next, you decide how you are going to dispose of the chemical waste you may generate in the lab. Never assume that liquid chemical waste is allowed to be poured down the drain. Some acids and bases that are poured down the drain will alter the pH of your wastewater. The Environmental Protection Agency (EPA) and the local wastewater authority will not be fans of that practice. Hazardous waste disposal requirements vary from state-to-state, so be sure to know the laws in your area for your place of business (see website: EPA Hazardous Waste Programs).
So now your chemicals stored properly, you know how to use them safely, but what is the plan when something unexpected happens? The accidental release of chemicals can be quite dangerous, and so can a poor response. A well written spill response procedure and periodic training can make clean-up a much less risky operation. The first and most important step is to correctly identify the chemical that spilled. Make sure staff know the location of your Safety Data Sheets (SDS), know how to access them, and that they are up to date. You may use an online database to access the SDS, and some services will even automatically update the SDSs to ensure you are viewing the most current version.
Make sure there is a spill kit in the lab that can effectively handle the accidental release of the different types of hazardous materials in your area. The kit should include the materials for a biohazardous spill as well. Ensure you have a well written procedure that describes the steps to safely and effectively clean up the spill. Your procedure should outline actions such as securing and surveying the site, donning the required PPE, laying down barriers to prevent spreading, and applying absorbents. Also include information about extraction of the clean-up material and proper disposal. Remember, the waste created from a chemical spill is considered a hazardous waste and must be treated as such. Absorbed chemical waste should be placed in a bag specially designated for hazardous waste (and segregated for offsite removal by your waste vendor.
The drafting of a CHP does take time and attention, but you cannot stop there. Your CHP is a living document that requires attention, and once it is created, you never want to let it go stale. It is important to keep your CHP fresh by updating it often. In fact, OSHA and most accrediting agencies require laboratories to review their CHP annually and assess its effectiveness. Keep staff knowledge about your CHP crisp. When staff know how to locate and use their CHP, they are more prepared to work safely with hazardous materials.
-Jason P. Nagy, PhD, MLS(ASCP)CM is a Lab Safety Coordinator for Sentara Healthcare, a hospital system with laboratories throughout Virginia and North Carolina. He is an experienced Technical Specialist with a background in biotechnology, molecular biology, clinical labs, and most recently, a focus in laboratory safety.
Gena was working in the microbiology lab when she failed to notice a possible N. meningitidis from a cerebrospinal fluid culture. Not thinking there was any danger, she prepped the organism for identification on the analyzer, but she used a vortexer that was not in the biological safety cabinet and did not cap the tube. The next day when she saw the organism identification, she realized she had created an aerosol the previous day in the open lab when co-workers were nearby. She was afraid of getting in trouble, so she did not report the incident. Three days later, Gena was in the hospital and not expected to recover. Two other co-workers had also fallen ill with minor symptoms. After the investigation, the manager did not relay the details of the incident to all of the staff fearing that the department would get in trouble with hospital administrators. One lab employee decided to call OSHA and report what she felt were unsafe working conditions.
There are at least three reasons it is important to create a safety culture in the laboratory where all staff members feel comfortable discussing potential safety issues, incidents, and near-misses. The first reason is so that every single safety incident in the department will be reported. Even something as minor as a paper cut that occurs within the walls of the lab should be reported. A tiny wound can quickly become an infection if skin is broken while working in an area where bloodborne pathogens are present. Staff should understand why reporting is essential, and they should be aware of the follow-up procedures that are put in place by the organization. To get lab employees to realize near-miss situations may be more difficult- there needs to be education about unsafe practices and potential consequences. For example, an employee might successfully retrieve a lost specimen from a sharps container without injury, but they and others should understand the high potential consequence of that action, and it should be reported. That is a tie to discuss unknown source exposures and potential impacts.
A second reason for a culture of transparency in the lab is to help the staff know the organization s working to keep them safe and to make them comfortable enough to talk to leadership about incidents and questions they may have about them. Sometimes, if employees feel leadership is not doing a good job of this, they will report to agencies outside of the workplace. It is easy for an employee to report incidents to OSHA, and if that happens, the lab will need to do much more work for the response. When an incident occurs, being open and honest about the details, the response, and the follow up to ensure it does not happen again can go a long way toward comforting staff. Hiding information just helps to generate rumors and a feeling by some that they are not working in a place that is doing all it can to keep their employees safe. It can be difficult after certain events to tell the story. While names may not be mentioned, it is likely in many situations that staff will know who the involved parties are. That is still better than hiding information. When OSHA responds to a safety report, even if the response is written and no inspectors come on site, the incident report and the written response from the organization must be posted in the department per regulation. The employees are going to know what happened either way. It is always best to be up front about incidents and to make staff aware that their safety is important and monitored, and that issues have swift follow-up.
Safety transparency also has a third benefit- it generates an overall better safety culture for the laboratory. When staff are comfortable reporting issues without punishment or pushback, and when they see they can work with leadership to continually correct issues, safety becomes a natural part of the job. Openly reporting incidents in staff huddles, discussing routine safety fixes and improvements, and educating about near-misses are all normal in a department where the safety culture is strong. A strong safety culture means fewer incidents and fewer injuries and exposures, a goal for which all labs should strive. Once Gena realized her mistakes in the microbiology lab, she should have felt comfortable enough to report them for her safety and for the safety of others in the department. Even if she were new to the field or to the department, her leadership should have conveyed to her how vital it is to report safety incidents or potential safety issues. When staff understand that their organization cares about them and will work to protect them, even when something goes wrong, they will feel confident they work in an environment where safety transparency is the norm, and where the safety culture is strong.
–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.
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