Laboratory Incident Investigation Policy

Policy

Laboratory incidents that impact personnel health and safety or environmental health will be investigated to determine the cause(s) of the incident and the actions necessary to minimize the likelihood of a similar incident from occurring in the future.

Responsible Authority

Vice President for Research and Innovation (VPRI); Environmental Health and Safety (EH&S) Department

Scope

This policy applies to incidents that occur in all teaching and research laboratories, and laboratory stockrooms and storerooms that are maintained by the University of Nevada, Reno.

Background

The University of Nevada, Reno laboratory safety program and radiation safety program are designed through proactive measures to prevent incidents such as personnel exposures to chemicals, biological agents, and ionizing and non-ionizing radiation; fires; and spills of chemicals, biological agents, and radioactive material. If an incident does occur, however, a prompt investigation is necessary to determine the cause(s) and corrective actions necessary to reduce the likelihood of a similar incident in the future. The purpose of the investigation is to gather information, determine cause, and recommend corrective action, not to assign blame or punitive action.

Reference Regulations or Guidance

  • 29 CFR 1910.1450, Occupational Exposure to Hazardous Chemicals in Laboratories
  • 29 CFR 1910.1030, Bloodborne Pathogens
  • 7 CFR 331, Possession, Use, and Transfer of Select Agents and Toxins
  • 9 CFR 121, Possession, Use, and Transfer of Select Agents and Toxins
  • 42 CFR 73, Select Agents and Toxins
  • CDC/NIH, Biosafety in Microbiological and Biomedical Laboratories, latest edition
  • NIH, NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules, latest edition

Nevada Administrative Code, 459.369 – 373, Requirements for reporting radioactive material incidents

Definitions

Incident: Any event that involves any of the following and which occurs in a laboratory or is associated with laboratory work:

  1. Personnel exposure to a chemical, biological agent, or ionizing or non-ionizing radiation at a level that exceeds maximum permissible regulatory levels, causes injury, illness, adverse health symptoms, or results in a medical evaluation or Workers’ Compensation claim.
  2. Personnel injury resulting from, or associated with, laboratory work. Injuries that require submittal of a notice of injury to the Workers’ Compensation Office are considered to be an incident under this policy; however, minor injuries that require only first aid treatment are not considered to be an incident.
  3. Spill or release of a chemical, biological agent, or radioactive material outside of primary containment, or spill or release to the outside environment above maximum regulatory levels or which may cause negative environmental impact. Minor spills that can be safely cleaned up by laboratory personnel are not considered to be an incident under this policy.
  4. Explosions, fires, and similar events that occur in laboratories or are associated with laboratory work.
  5. Any other safety, health, or environmental event that involves significant regulatory non-compliance or breach of procedure, or which may result in negative public attention to the university.

Laboratory Supervisor

Person who has been assigned responsibility for a particular laboratory space or activity. For research laboratories the supervisor is the principal investigator (PI), and for teaching laboratories the supervisor is the instructor of record.

Responsibilities

Deans, Department Chairs, and Directors

Ensure that laboratory supervisors are aware of the responsibilities and procedures contained in this policy, and provide administrative enforcement of this policy.

Laboratory Supervisors

Ensure that all laboratory personnel are aware of incident reporting and investigation procedures specified in this policy.

Ensure that laboratory incidents are reported and investigated in a timely manner as specified by this policy. In particular, laboratory supervisors are responsible for ensuring that incidents are reported to EH&S and administrators, and that incidents involving employee or student injury, illness, or exposure to chemicals, biological agents, or ionizing or non-ionizing radiation are reported to the Business Center North (BCN) Risk Management/Workers’ Compensation group.

Ensure that identified corrective actions assigned to the laboratory are completed in a timely manner.

Environmental Health and Safety Department

Ensure that reported laboratory incidents are investigated as specified by this policy by providing guidance to laboratory supervisors, administrators, and the appropriate university safety committee, and coordinating incident reporting, notification, and investigation, all as needed or requested.

University Safety Committees

As requested, provide technical expertise to the incident investigation and review process. Review laboratory incident reports to include specifying additional investigative actions and corrective actions as needed.

Make recommendations to the vice president for research and innovation, up to suspension or closure of laboratory space or operations, as deemed appropriate and as specified by the approved committee operating procedures.

Laboratory Personnel

Report laboratory incidents and participate in investigations as specified by this policy.

Procedure

Campus Notifications

  1. The laboratory supervisor or laboratory personnel must report all laboratory incidents to EH&S within two business days. For an incident that requires a rapid response or which is of a serious nature, notification must be made as soon as possible.
  2. EH&S must notify Police Services as soon as possible of significant incidents by calling the shift duty officer at 775-745-6195. Examples of incidents that require immediate police notification are those that involve the following:
    1. Spills or releases of chemicals, biological agents, or radioactive materials that require a response from EH&S or a hazardous materials team. Spills or releases that can be safely cleaned up by laboratory personnel do not require reporting to Police Services.
    2. Smoke or fire
    3. Explosions or other similar physical incidents.
    4. Unsafe air quality issues.
    5. Personnel injuries or exposures to hazardous materials that require evaluation or treatment by a healthcare professional.
    6. Response by emergency responders (ambulance, firefighters, or hazardous materials team).
    7. Any incident that involves evacuation or restricted access of a room or building, or significant disruption of building access or normal building business or personnel flow.
  3. The laboratory supervisor or laboratory personnel must immediately notify the responsible department chair or administrative office of laboratory incidents in accordance with department policy or practice.
  4. The laboratory supervisor’s dean, the vice president for research and innovation, assistant vice president for research administration, and other University administrators as appropriate, must be notified as soon as possible of incidents that involve significant personnel injury or illness, environmental release, regulatory investigation or action, potential legal liability, or public attention.
    1. The laboratory supervisor, department chair, or other individual designated by the chair is responsible for ensuring that the responsible dean has been notified.
    2. EH&S is responsible for ensuring that the vice president for research and innovation and the assistant vice president for research administration are notified immediately.
    3. The University director of communications must be notified of incidents that involve media coverage, and media requests for information should be directed to the director of communications. EH&S will notify the director of communications of such incidents.
  5. The laboratory supervisor or other designated department individual is responsible for reporting incidents involving injury, illness, or personnel exposure to chemicals, biological agents, or ionizing or non-ionizing radiation to the BCN Risk Management/Workers’ Compensation office as soon as possible. Incidents involving employees and declared volunteers must be reported for Workers’ Compensation purposes, and incidents involving non-employees (for example, students or visitors) must be reported for potential liability purposes.

Regulatory Notifications

  1. EH&S will make any notifications to regulatory agencies that are required for environmental health and safety purposes.
    1. The chair of the Institutional Biosafety Committee may make required notifications to the National Institutes of Health regarding incidents involving biological agents.
    2. The chair of the Radiation Safety Committee may make required notifications to the Nevada State Radiation Control Program regarding incidents involving radioactive materials.

Investgation

The exact scope and procedure used to investigate a specific laboratory incident will be determined by the EH&S assistant director for laboratory safety, radiation safety officer, or the EH&S director. Typical procedures for investigating incidents are outlined below; however, there may be some deviation to these procedures depending on the specifics of the incident.

Investigation of incidents that involve significant personnel injury or illness, environmental release, regulatory investigation or action, potential legal liability, or public attention may involve a broader scope and/or an investigation committee. This level of investigation will typically be requested by the vice president for research and innovation or other higher level administrator. Investigation of these types of incidents will typically be broader in scope, more detailed, and require communication with administrators throughout the process; however, the basic procedure is the same as that listed below.

Typical Investigation Procedure for Incidents Involving Chemicals, Biological Agents, or Physical Injuries

  1. These incidents will be assigned to the EH&S laboratory safety group for investigation and follow up; however, if that group is not available the assignment can be given to another member or group within the EH&S Department.
  2. EH&S will request that the laboratory supervisor provide a written report of the incident that includes at least the following information:
    1. Description of the incident that includes the work that was being performed, safety procedures and precautions implemented at the time of the incident, personal protective equipment worn at the time of the incident, and any other circumstances pertinent to the incident.
    2. Immediate response actions.
    3. Any additional or follow up response actions (for example, medical care, hazardous material clean up, etc.).
    4. Direct cause(s) of the incident.
    5. Root cause(s) of the incident (what led to the direct cause(s)?).
    6. Proposed corrective actions to address the direct and root cause(s) and prevent a similar incident from occurring.
    7. Completion dates for proposed corrective actions.
  3. EH&S will review the incident report provided by the laboratory supervisor and request additional information as needed. At its discretion, EH&S may collect information pertaining to the incident, including conducting interviews of personnel involved in the incident.
  4. EH&S may ask the laboratory supervisor to revise the incident report, to include the addition of corrective actions and due dates.
  5. Incidents that involve chemical exposure, reactions, spills, or releases will be reviewed by the Laboratory Safety Committee. Incidents that involve exposure to biological agents, or spills or releases of biological agents will be reviewed by the Institutional Biosafety Committee. The reviewing committee may ask for revisions to the incident report, to include the addition of corrective actions and revision of due dates. The reviewing committee can also recommend suspension of laboratory operations or other penalties to the vice president for research and innovation as it deems necessary.
  6. After review by the appropriate safety committee, EH&S will communicate the results of the committee’s review to the laboratory supervisor and the responsible department chair. If revisions are requested by the committee, the laboratory supervisor will be asked to make the revisions and provide a final version of the incident report to EH&S and the responsible department chair.
  7. EH&S will send copies of the final incident report to the responsible dean and other higher level administrators as is appropriate for the incident.
  8. The laboratory supervisor is responsible for ensuring that the corrective actions contained in the final version of the report are completed as specified and by the assigned due dates, and for notifying EH&S when corrective actions are completed.
  9. EH&S will follow up with the laboratory supervisor to ensure completion of corrective actions.
  10. When all corrective actions have been completed EH&S will send a report or notification to all individuals who received the final investigation report to indicate closeout of the incident.

Investigation of Incidents Involving Radioactive Materials or Personnel Exposure to Ionizing or Non-Ionizing Radiation

  1. The radiation safety officer (RSO) will conduct an investigation of the incident. Similar to the procedure described above, the investigation will typically involve:
    1. Collection of information regarding the circumstances of the incident and response actions.
    2. Identification of direct causes and root causes of the incident.
    3. Identification of required corrective actions and completion dates.
  2. The RSO will provide a written report of the incident, which includes all pertinent information and corrective actions, to the Radiation Safety Committee for review. The committee can ask for revisions to the incident report, to include the addition of corrective actions and revision of due dates. The committee can also recommend suspension of laboratory operations or other penalties to the vice president for research and innovation as it deems necessary.
  3. The final written report will be provided to the laboratory supervisor and the responsible department chair.
  4. The vice president for research and innovation will be provided with a copy of the final report for all incidents that are required to be reported to the Nevada State Radiation Control Program, and other incidents as is appropriate.
  5. If the incident is required to be reported to the Nevada State Radiation Control Program the RSO will typically make that notification; however, the chair of the Radiation Safety Committee can also make the notification.
  6. The laboratory supervisor is responsible for ensuring that the corrective actions contained in the final report are completed as specified and by the assigned due dates, and for notifying the RSO when corrective actions are completed.
  7. The RSO will follow up with the laboratory supervisor to ensure completion of corrective actions.
  8. When all corrective actions have been completed the RSO will send a report or notification to all individuals who received the final report to indicate closeout of the incident.

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