We do it several times a day, every day we work in the laboratory. We disinfect, but how much do we really think about what we are doing? Some may think we disinfect our benches at the end of the shift because it is expected, and that we only perform this task because it is listed on our maintenance log. Others disinfect at the beginning and at the end of their shift because of how they were trained. Since the pandemic, I bet many lab techs, nurses, and hospital staff disinfect religiously out of fear of catching COVID. The real reason we disinfect is to keep ourselves, our coworkers, and the people we care about safe.
As laboratorians, we have practices to preemptively and proactively ensure that the samples and patients we work with do not put us in harm’s way. We clean and disinfect anytime we have a spill of patient specimen. With that spill we know there is a potential for exposure, and we take steps to remove the threat. We also routinely disinfect our work areas throughout the day to eradicate any unseen pathogens. It is easy to visually spot a spill of whole blood, but a few drops of serum or plasma can easily go undetected.
To keep everyone safe, we need to fully comprehend the difference between “cleaning” and “disinfection.” Cleaning is the act of removing the physical component of a spill, sample, or mess. This could be dirt, dust, blood, body fluid, or even a piece of tissue. If there is a spill of blood on the floor, we first clean up the spill by applying an absorbent and sweeping up the material. We can see that the blood is removed from the floor, but what we cannot see poses the most danger. Simply cleaning up a spill does not kill any potential pathogens. We still have one more step, disinfection.
Disinfection is the process of killing the pathogens and it must take place after cleaning. Only after we disinfect is the area considered safe. It takes both the cleaning and disinfection steps to make sure the spill is properly handled. Spraying bleach directly on a blood spill and wiping with a paper towel may leave pathogens under the spill lurking on the surface of the floor or counter. For disinfection to be the most effective, it is essential to expose the potential pathogens to the disinfectant, and cleaning helps remove any barriers.
We have the why behind the process, so let’s discuss how we disinfect. Our best defense against most pathogens is bleach. Ah, the glorious smell of bleach; either you love it or hate it. Bleach is one of the few products that can effectively neutralize Clostridium difficile. That is why bleach is used for benchtop and post-spill disinfection. In the lab setting, we typically see two types of bleach products, a spray and wipes. Each has their own minimal contact time, so make sure to leave the product on the area for the allotted amount of time. Bleach wipes typically require a longer contact time than bleach spray. It is also important to make sure the lids on any disinfectant wipe container remain closed when not in use. If the lids are left open, the wipes can dry out, making them a less effective disinfectant.
Some labs may allow for a bleach alternative when employees with a bleach allergy are present in the lab. Individuals with a documented bleach allergy may be permitted to use alternatives such as a concentrated broad-spectrum quaternary agent as a means for disinfecting. Usually, approval must come from an organization’s employee health or physician to accommodate the request. As with bleach wipes, quaternary disinfectants may require a longer contact time than your usual bleach spray.
You may see products from other manufacturers that use alcohol with an ammonium chloride ingredient. Many labs use these types of disinfectants in areas to eliminate the residue seen when using a bleach product, such as cleaning stainless steel biological or chemical safety hoods, glass, or other office appliances. Often, alcohol or ammonium chloride disinfectants are used on telephone headsets, computer screens, select Point of Care instruments, and other items for which bleach is prohibited. In addition, some instrument manufacturers recommend only using a particular product to clean the surface of their equipment to ensure the cleaning does not damage the outer casing or internal components. Sometimes, though, staff will accidentally substitute these types of products in place of bleach when it is time to disinfect at the end of the shift or help with a spill. It may be convenient to just grab a bottle of an alcohol-based disinfectant and jump into action. However, it is more important not to take short cuts and locate a bottle of bleach spray and disinfect the proper way. Sometimes it may seem like a hassle, but disinfection is part of our laboratory culture, and we need to keep up with the practice. If we maintain our disinfection routines, there is no reason to doubt our safety inside and outside of the lab. You can take it a step further and always be on the lookout for expired products or open lids to ensure your products can do their jobs effectively. Understanding why we perform these tasks and the importance they have for our safety is something that should be shared with all employees. Together, with the right mindset, you can be confident that your lab is a safe, clean, and properly disinfected 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.
Inspections are a great learning opportunity. Our recent American Association of Blood and Biotherapies (AABB) introduced us to the risk analysis requirement in its 2024 checklist. Though the requirement is specifically stated in 3.7 Information Systems #13, the requirement can be applied to instruments as well as software. The update is significant as it emphasizes the need to proactively identify, assess, and mitigate risks associated with introducing or modifying software and instruments within the laboratory setting.
AABB-accredited laboratories will need to review their validation procedures to ensure they include a risk analysis with mitigation for identified risks. There are a few steps to conducting a risk analysis.
First, clearly define the changes being made. This could include new software installations, updates to existing software, introduction of new instruments, or modifications to current equipment. Understanding the full scope of changes is essential for a comprehensive risk analysis.
Secondly, if possible, form a multidisciplinary team that includes IT specialists, laboratory managers, quality assurance personnel, and end-users. In reality, for many small to medium laboratories, frequently one person fills more than one role. It’s conceivable for the laboratory manager to be the quality person and an end user since they often may have to fill in during staff shortages.
Next, identify the risks. Structured techniques like Failure Modes and Effects Analysis (FMEA) can be used to identify potential risks. Consider software-based risks such as data loss or corruption, system incompatibility, user interface issues, and cybersecurity vulnerabilities. Calibration errors, operational failures, compatibility with existing systems, and maintenance requirements are some instrument-based risks that should be considered. And, of course, human-based risks involving user errors, poor or insufficient training, and workflow disruptions.
The fourth step would be to assess each identified risk, assessing its potential impact on laboratory operations and patient safety and evaluating the likelihood of occurrence and the severity of consequences if the risk materializes. Use a risk matrix to categorize risks as low, medium, or high.
For each high or medium risk identified, develop mitigation strategies to reduce the likelihood of occurrence or minimize the impact. Some examples are increasing training programs, additional testing, or developing contingency plans for failures.
Ensure the entire risk analysis process is documented, including the identified risks, evaluation results, and mitigation strategies. Documentation is crucial for compliance with the AABB checklist and is a reference for future audits or inspections.
The risk analysis requirement in the AABB’s 2024 checklist underscores the importance of proactive risk management in clinical laboratories. Through the implementation of the outlined steps, laboratories can not only meet this requirement but also enhance their operational resilience and commitment to patient safety. Conducting a thorough risk analysis for software and instrument changes is an investment in the quality and reliability of laboratory services, ultimately contributing to better patient outcomes.
-Darryl Elzie is the Regulatory Affairs Manager Inova Blood Donor Services. He has been an ASCP Medical Laboratory Scientist for over 25 years, performing CAP inspections for two decades. He has held the roles of laboratory generalist, chemistry senior technologist, and quality consultant. He has a Master’s in Healthcare Administration from Ashford University, a Doctorate of Psychology from The University of the Rockies, and is a Certified Quality Auditor (ASQ). Inova Blood Donor Services is the largest hospital-based blood center in the nation. Dr. Elzie is also a Counselor and Life Coach at issueslifecoaching.com.
In the hazardous and dynamic environment of the laboratory, precision and safety are paramount, and it is crucial to both understand and adhere to proper safety protocols. Despite comprehensive training and strict guidelines, lapses in safety practices still occur, and in many labs, these deviant behaviors are the norm. One powerful tool to bridge the gap between knowledge and practice is the sharing of personal stories about the consequences of laboratory injuries and exposures. This storytelling can enhance compliance with personal protective equipment (PPE) use, and it can even foster safer lab work practices.
Stories are a fundamental part of human communication. They resonate with us on a personal level, making abstract concepts tangible and memorable. In the context of laboratory safety, sharing real-life incidents of injuries and exposures can drive home the importance of following safety protocols in a way that theoretical training cannot.
Consider the case of a histology technician who suffered a severe laceration because they used their bare hand to handle a cutting blade as it was being replaced on the microtome. Hearing this technician’s account of the pain, the disruption to their work, and the long recovery process is far more impactful than a generic reminder to always use implements or cut-resistant gloves to handle blades. It personalizes the risk and underscores the real consequences of non-compliance.
Understanding the potential consequences of unsafe lab practices is vital. Many lab workers know the rules but might not fully appreciate the risks involved in breaking them. Let’s delve into three common unsafe practices and their possible repercussions.
Using Cell Phones in the Lab
The use of cell phones in the laboratory is a growing concern. Phones can be a source of distraction, but more importantly, they can harbor contaminants. Imagine a scenario where a lab worker uses their phone in a biohazard area. Pathogens from their gloved hands can transfer to the phone’s surface. Later, they use the same phone outside the lab without proper decontamination, potentially spreading harmful agents to themselves, colleagues, or even their family.
I recall a story from a colleague who witnessed a near-miss incident involving a phone. A technician was distracted by a text message and accidentally knocked over a beaker of caustic chemicals. Fortunately, no one was injured, but the incident was a wake-up call about the dangers of distractions in the lab. This story is one way to highlight the importance of keeping personal devices out of the laboratory environment.
Eating or Drinking in the Lab
Despite clear prohibitions, some lab workers still eat or drink in the lab, often thinking that it is harmless if they are careful. However, the risk of contamination is significant. A real-life example involved many lab workers who developed a serious gastrointestinal infection after unknowingly ingesting a pathogen that had contaminated their food. They had been eating at their workstations, where they also processed clinical specimens.
This case underscores the critical importance of designated eating areas and the strict separation of food and drink from laboratory activities. Sharing such stories can vividly illustrate the hidden dangers of complacency and reinforce the necessity of adhering to safety protocols.
Not Using PPE When Necessary
On the Hierarchy of Controls, PPE is the last line of defense against many laboratory hazards, yet some workers skip this vital protection for the sake of convenience or comfort. The consequences of such decisions can be severe. For instance, a lab worker handling corrosive chemicals without proper eye protection suffered a splash injury, leading to partial vision loss. Hearing this person’s experience, from the immediate pain and panic to the long-term impact on their life and career, can be a powerful motivator for consistently using PPE. It is likely there are several other real stories in your own labs that can be used.
To foster a culture of safety in the laboratory, it is essential to create an environment where sharing stories about injuries and near-misses is encouraged and valued. This openness helps to demystify safety protocols and makes the abstract risks more concrete. There are strategies to build this culture.
Create forums for lab workers to share their experiences without fear of blame or retribution. This could be in the form of regular safety meetings, anonymous reporting systems, or informal discussions. The key is to ensure that these stories are used constructively to improve safety practices.
Integrate real-life stories into safety training sessions. Use the narratives to illustrate the importance of compliance and to discuss what went wrong and how it could have been prevented. This approach not only makes the training more engaging but also more relatable.
Lastly. Lab leadership plays a crucial role in shaping the overall safety culture. Managers and senior staff should model safe behaviors and share their own experiences with safety lapses and near-misses. When leaders demonstrate a commitment to safety, it sets a powerful example for the entire team. Stories can be a potent tool for enhancing laboratory safety. By sharing real experiences of injuries and exposures, we can bridge the gap between knowing and doing, making the importance of safety protocols vividly clear. In a laboratory setting, where the stakes are high, these stories can drive better compliance with PPE use and foster a culture of safety that protects everyone. Remember, every story shared is a lesson learned and a step towards a safer work environment 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.
When you get into your car, what’s the first thing you do? Perhaps you are the sole owner/operator of that vehicle and can just slide in, fasten your seatbelt, and take off. If you share a vehicle, driving away may take a few extra steps. My wife and I sometimes share vehicles, so I know when she has to take mine to work or to run an errand. I can tell right away if my wife was the last to drive my car because my knees are pressed up against the steering wheel the moment I get in. I have to slide the seat away from the dashboard and recline the backrest. I am a bit taller too, so I have to move the entire seat down, otherwise my head would be jammed up against the top of the headliner. Once I make it more comfortable, only then can I adjust the mirrors to ensure that I can safely see around the vehicle. Now my legs are at the correct distance from the pedals to ensure smooth transition from brake to accelerator. My arms are at the perfect distance from the steering wheel and the cup holder which has my essential jug of coffee. Most importantly, the seat belt comes over my shoulder and across my chest at an angle that ensures I am secure while not being strangled by the belt. A lot goes into ensuring smooth and safe operations of the vehicle, all stemming from that initial adjustment of the seat. The same goes for the lab. Whether you are sitting at a low desk or at an elevated workbench, you should adjust your chair height and recline. This important initial step can make or break the ergonomic setup of your workstation.
When I work at a shared bench or workspace, I first like to adjust the height of the chair. This ensures that my legs are positioned properly, with my knees at 90° angles with feet flat on the floor or on a footrest. I make sure that the height of the chair is not too high so that I have to jump into the seat or risk twisting an ankle when I get down from a taller task chair. A proper chair height in relation to the desk or bench also makes sure that my body is aligned properly with my workbench. My knees aren’t slamming into the bench, and my arms are at the correct height in line with the keyboard, also forming 90° angles from my body. Now that my body is positioned properly, I can ensure that my monitor is at the correct height with my head aligned with the top of the monitor. I reposition the mouse and keyboard, so they are at the correct distance from my body, and that I am not overreaching to type. Don’t forget the wrist rest – relieving the pressure on the base of the wrist is key in preventing carpal tunnel syndrome. In addition, if you use the angle-adjusting stands at the back of the keyboard, wrist rests are a must to straighten your wrists. Another great tool to avoid ergonomic complications is the 20-20-20 rule, which helps reduce digital eye strain. Many of us in the lab industry are looking at computer screens for much of the day. The 20-20-20 rule teaches us that every 20 minutes, we should shift our gaze away from our monitors and look at an object at least 20 feet away for 20 seconds.
Shared workstations are common in the lab and in some office spaces as well, and these ergonomics tips can apply to both areas. Of course everyone has their favorite chair in the lab. It’s never good to see someone getting upset because someone stole “their chair” or changed the height of “their chair”. That’s what people are supposed to do. We should be encouraging individuals to adjust their workstation to make it more ergonomically efficient for them. Everyone should take a few minutes when we arrive in the lab or office to set themselves up appropriately.
You may be wondering what else you can do to help ensure ergonomic safety in your workplace. If your lab is CAP-accredited, you should follow the general checklist item GEN.77200. This standard states that there must be a written ergonomics program to help prevent muscular skeletal disorders in the workplace through prevention and engineering controls. So just having a policy isn’t good enough, you need to show that you’re actively participating in ergonomic evaluations and recommendations as well as implementing the appropriate corrective actions from your findings. We all know the lab environment is a dynamic one, one that’s constantly changing. So, your ergonomics evaluations might become outdated quickly. It’s great practice to include an ergonomics section in your lab safety audit and to use it regularly. This will ensure that your workstations and lab environment are checked annually for any areas of opportunity.
Of course, there’s much more to ergonomics than just adjusting your chair or computer. It’s the same as with your car- there’s more to driving than simply adjusting your seat. If you can’t see the vehicles around you or can’t reach the pedals fast enough, the consequences of those errors could be an accident which is immediate and can happen in the blink of an eye. Years of stretching, bending, or sitting improperly will take a toll on the body that might not be realized in the moment. We won’t see the aftereffects until it’s too late. In the fast-paced world we live in, we sometimes forget about taking a moment to ensure our safety at work, but we should. It’s difficult to operate your vehicle if you’re uncomfortable and can’t reach the pedals, but you are likely to adjust your seat before you start driving. Take that moment to think about good ergonomics before you slide into the driver’s seat at work.
-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.
Change is inevitable. Humans naturally resist change, and it is a leader’s responsibility to help inspire their followers to embrace the continuous improvement mindset and become change agents. Clearly, this topic is dear to me as it fueled my dissertation. In laboratory medicine, we’re privy to some remarkable technologies, yet our fear of being replaced by technology often outweighs our curiosity. I can promise you, at least in our lifetime, laboratory professionals will not and cannot be replaced by technology. I remember back in my cytology program (yes, it’s been a decade, and no, we don’t need to discuss that further), seasoned cytologists were panicking about molecular testing. They’d say, “we’re done. They’re not going to need us anymore! Look for another career because you’re wasting your time here.” I’m not sure why I never believed them, or maybe I’ve just never been able to fully trust AI and that gave me some sense of security. Regardless, I persevered and fell in love with our field. In school, I learned about telepathology. Users were able to attach a camera to a microscope and capture static and dynamic images of pathology slides for digital archiving and for performing consultations rapid onsite evaluations (ROSE). Institutions were piloting novel yet comprehensive systems for ROSE so that cytologists could attend the biopsy procedures to prepare and maneuver the slides, allowing the pathologist to perform an adequacy assessment remotely. I thought it was fascinating and such a phenomenal use of resources.
Cytology is both an art and a science, as Dr. Richard DeMay so eloquently described. From a scientific standpoint, there has been substantial effort in developing imaging algorithms that systematically capture the unique features of dysplastic and malignant cells and differentiate them from benign-appearing cells. My first experience with this was the ThinPrep Imaging System (TIS), which helps reduce the rate of false-negative pap smears by providing 22 fields of view that may prompt a full manual review. I can comfortably say that, even after more than a decade, this system has not replaced the human eye, but assisted in our primary screening. Now with AI advancement, the Genius Digital Diagnostics System was designed to expand upon computer-assisted screening. The Genius system not only identifies features of dysplasia, but suggests benign components that are fundamental to the overall diagnosis, such has glandular cells and microorganisms. Presenting these fields in a gallery view along with the whole slide digitally imaged enables the user to better classify the whole picture and review cells surrounding the gallery-selected objects of interest. For someone who has missed a single pseudohyphae of candida lurking between a few squamous cells (hi, it’s me), this technology is a game-changer. Again, this is not a substitute for the cytologist because the cytologist is still responsible for primary screening and rendering a diagnosis. With that said, technology is not perfect. To err is to human, to fault is to… technology. But in a world where cytologists are afraid that HPV primary testing will replace the need for cytology, the continuous development of digital cytology for gynecologic specimens is ever in our favor. Just like there will always be HPV-negative dysplasias, there will always be cells that technology won’t capture, the skilled art that we practice will always have a critical value in patient care.
On the educational and logistics front, imagine being able to digitally archive study sets from the most unique cases your institution has seen. Whole slide imaging (WSI) and Z-stacking technology enables a user to create and access an expansive digital reference library with the ability to zoom in and focus on fields of view from a computer screen. Yes, I prefer using a microscope just as I prefer reading a paperback book, but the world has adopted e-books, so I’m fairly certain we can adapt to e-slides as well. Regardless, publishing and sharing a digital reference set is beneficial to the field of anatomic pathology, whether you’re studying for a board exam or rendering a diagnosis on an unknown by comparing to previously diagnosed cases elsewhere. Logistically, the same principle applies for pathology consultations. The idea of never losing a patient’s original slide in the mail is titillating. Digitalizing pathology slides for consultation and sending the file to another institution through a secure server is more efficient yet just as diagnostic as a traditional consultation through the mail.
But wait! There’s more. AI technology can help us interpret ancillary tests, such as FISH/UroVysion. It is still up to us to agree with the machine’s classifications, but tools like this can ideally reduce turnaround time. Pathologists are already familiarizing themselves with algorithms for IHC and predictive biomarkers. Larger academic medical centers are securing grants left and right to develop and train both diagnostic and prognostic algorithms. Digital pathology can improve efficiency, reallocate our resources, and serve as an aid.
Granted, these technologies are costly and require ample digital storage space. I’m talking petabytes of data here, and of course, there’s a need for impenetrable security in the cloud. WSI can be tedious and time-consuming, and may even warrant the need for an additional full-time employee (or two). Additionally, many of these technologies require extensive validation. Other than cost and storage, one of the more significant challenges in digital cytology is adequately capturing a variety of cytopreparations. Unlike smooth histology sections, cytopreparations including smears, cytospins, and even liquid-based preparations, preserve (to some extent) the three-dimensional nature of cell groups. While it’s beautiful to be able to manually fine-tune our focus throughout a cluster of cells under the microscope, AI may struggle with capturing and systematically categorizing cells within these groups or clusters. Current technologies that work well for histology slides might be insufficient for cytology slides, which serves as a hurdle for research and development teams and a barrier to users embracing a technology that has not yet been “perfected” for a field.
Digital cytology is relatively young, and like any early technology, there are going to be bumps and hiccups. With that said, the benefits of digital pathology overall far outweigh any possible negatives, and we must continue to move forward. We, as laboratory professionals, cannot slow down and resist the future of our field. We must serve as change agents and reassure our future colleagues that there is a secure place for them pathology and laboratory medicine. This is my call to all of you to let your curiosity take over. Take the plunge and let technology be your ally, your diagnostic companion.
Note: I have no financial interests or relationships to disclose. Opinions are purely my own and are not representative of my employer or ASCP.
-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.
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.
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.
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.
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.
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