Investigation of eye splash and needlestick incidents from an HIV-positive donor on an intensive care unit using root cause analysis.
BACKGROUND
Two doctors working on a busy intensive care unit sustained injuries whilst removing a chest drain from an HIV-positive patient. One doctor had a needlestick injury into his finger whilst the other sustained an eyesplash when the chest drain was pulled out.


METHODS
Following Department of Health format 'Doing less harm', a root cause and human factor analysis of the incident was carried out. The aim was to explore the underlying issues.


CONCLUSIONS
Training, cultural and organizational issues were exposed, and are now being addressed. This approach has led to a far more effective dialogue with the National Health Trust concerned than was previously experienced, and there is early evidence of progress on important aspects of health and safety management at organizational level. Lack of health and safety training of doctors at undergraduate and postgraduate level needs to be addressed.
Batty
L
L
Department of Occupational Health and Safety, Kings College Hospital, Denmark Hill, London SE5 9RS, UK. luciabatty@yahoo.com
Holland-Elliott
K
K
Rosenfeld
D
D
D000062:Accidents, Occupational; D005123:Eye; D006679:HIV Seropositivity / Q000635:transmission*; D006801:Humans; D017758:Infectious Disease Transmission, Patient-to-Professional; D007318:Inservice Training / Q000592:standards; D007362:Intensive Care Units; D016602:Needlestick Injuries / Q000209:etiology*; D009784:Occupational Diseases / Q000209:etiology*; D012307:Risk Factors; D017751:Safety Management