When lab incidents happen, it’s tempting to look only for the proximal cause: a broken piece of equipment, a missed step, a moment of distraction. The solution then seems obvious: replace the equipment, follow procedures, pay attention. This satisfies our very human desire to find a quick fix and move on. But this does not prevent the same thing from happening to the next person.
Finding the root cause
Root cause analysis asks us to dig deeper and identify the underlying reasons why an incident occurred. This leads to more powerful and effective solutions. Root cause analysis doesn’t have to be difficult. It can be as simple as asking, “Why?” repeatedly.
For example, if equipment fails, that is the proximal cause. To find the root cause, ask yourself, “Why did it fail?” Perhaps the equipment did not get the appropriate preventative maintenance. “Why was maintenance not done?” No one remembered to do it. “Why did no one remember?” It was not assigned to anyone.
Preventing future incidents
Addressing the proximal cause, replacing the equipment, is not enough. A more complete solution addresses the root cause, in this case, designating someone to oversee preventative maintenance for the equipment to prevent future failures.
Thinking about the underlying causes of incidents can also help us prevent them. Imagine how someone could be hurt in your lab. Now ask yourself, “What conditions could allow that to happen, and how could those conditions could be improved?” Reorganizing your workspace so you can reach the sharps container can prevent a needlestick. Carrying tubes in a rack can prevent a spill. Using a brush instead of a tissue to clean the microtome blade can prevent cuts. What can you change today to prevent tomorrow’s incident?
by Andrea Ladd
Andrea Ladd is the Director of Biological Safety – Biological Safety Officer. She joined EHS in 2016 and oversees the Office of Biological Safety, including IBC and Laboratory Operations, Animal Research Safety, Select Agent/DURC Program, and Biocontainment Program.
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