DFIAFT - Hot for distribution - may contain sensitive inyormation or factual errors. Clinic Lab Incidents - Selected Incidents Date Injured Medgate 111? Description Safety Building Incident description Comments Information Description Description Source 6-"12-"2014 14 114-51:l NCEZID DIV OF Potential alrbome exposure Staff member not in area on day ol possible exposure. 2Ci4 i??t?-lit el (migrag FOODBOFINE. Not considered potentially exposed. sods-re WATERBORNE 3. 252a .x ENVIRONMENTAL to. 262mm DISEASES . 06-05-2014 14 11495 BUILDINGS airborne exposUre Staff member not in area on day ol possible exposme. AND FACILITIES Not considered potentially exposed. 252a OFFICE FMEO 14-11495 OCOO BUILDINGS airborne exposure ISICI Staff member not in area on day ol possible exposure. I: I AND FACILITIES Not considered potentially exposed. OFFIOE .l FMEO -- 14 11394 Potentlai exposUre tol I Staff member not in area on day ol possible exposUre. (mfa) 42 Not considered potentially exposed. I I rt t: os-?oe?aom 14-11414 NCEZID DIVISION Potential exposure tol I 3 Patient was seen on one. we and rlle. On OF SCIENTIFIC vaccination IND schedule and on Cipro. No nesounces ea date. - 14 OCOO BUILDINGS airborne exposure Staff member not in area on day ol possible exposure. AND FACILITIES Not considered potentially exposed. OFFICE FMEO 14?1 15:18 GOOD BUILDINGS airborne exposure Staff member not in area on day all possible exposure. AND FACILITIES Not considered potentially exposed. OFFICE FMEO 14-1154? NGEZID DIVISDN OF Potential exposure ruled out because employee was not _Em Io ee concerned that skin lesion wasl I HIGH- exposed to affected room Possibility was ruled out. -- CONSEQUENCE . b. .3 942 5.0. I PATHOGENS AND II I 5- 2523 Pne 2525th 262ath 14-11546 0000 BUILDINGS exposUre. no illness Staff member not in area On day ol possible exposUre. AND FACILITIES Not considered potentially exposed. OFFICE FMEO 4 14-11536 Potential exposure to I (3)142 Staff member not in area on day at possible exposure. Not considered potentially exposed. 14?10312 DIVISION potential airborne exposure to M. tuberculosis '53 BLDG 1.7 A Researcher found cap off broth tube. Researcher ESCHO OF TUBERCULOSIS 262a was not wearing respiratory protection. No tMedgate-WIMSJ ELIMINATION LB reported to date. No conversion to first TST. second pending. File-searcher has been contacted by for second test. 14-9412 possible exposUre to TB See notes section CDC statt in Texas talked with patient. Patient revealed Fxtema exposul'e ESCHO potential TB exposure. Baseline and 8 week post [Medoate-WIMSJ exposure TST were negative. 13-?454 NCEZID DIVISION Ferret bite to Ft index linger BLDG 23 Animal was in quarantine and was nai'tre. No exposure It-lproper PPE ESCHD OF SCIENTIFIC -. -. to infectious a ents. Stall advised to have ayallable [Med nesounoes OD 2523 h" as animal aweiiene. [ii-"35342 U-S-C- 2523i?: 9 Dalila-Ema 13-5531 NCIRD INFLUENZA manipulated specimen that was lilter aerosclized Handled possipl a -- -- egosol at an mmaine? DIVISION ysoe [mg-H42 U30 2523? -. confirmed by - - wont perrormeo withih a 0 exposure occurred. 5i worked. :h.ls no E2a[h:: - - x? 2523M: ?3.13.1342 252m?? USSR-2013 13 504B NCEZID DIVISON OF bite to right hand: scratch to left hand I Animal had been Inoculated with raccoonpo'x. but was Incorrect-g our: typo ..scd HIGH- ?3:13:42 u_s_c_ 352mm not yiremic at the time. Use of protective gloves .. I. .. CONSEQUENCE recommended. Baseline serum was drawn. but U39 252ml.? PATHOGENS AND researcher ha In 2011. 3:242 USE. 2523M: PATHOLOGY USC. 25231-i?1 I r. 13 48.53 NCEZID DIVISION Risk of exposure through Inhalation Possible Chiltungunya exposure through broken ESLHO CIF VECTOR-BOBBIE tube brought out of BSD. Researcher was wearing [Medoate-WIMSJ DISEASES ADB gloves and lab coat. but no respiratory protection. Researcher was seen in clinic on 4:25 and 4:29. F'ost ineldent baseline drawn. No reponed and no titer observed for Chlkungunya. No medications given. osrosraots 14-1019? Potential exposure to TB BLDG to Employee was working with commercially purchased extremal commencal ESCHID pooled sputum and handled at BSL2 in a BSC. A sample was requested by TB and they discovered DNA in the sample. No free organsisms Iwere ever purchase of sample cultured. tMedgate-WIMSi 5 - Hot for distribution - may contain sensitive invorrnation or factual errors. Clinic Lab Incidents - Selected Incidents cane-ems 14-1017? NCEZID I DIVISION exposure to possible MDB TB Employee was working with commercially purchased ESCHO OF SCIENTIFIC pooled sputum and handled at BSL2 in a. BSC. A [Medgate-?WIMSI RESOURCES BE sample was requested by TH and they discovered DNA in the sample. No the organsisms were ever cultured. 03-?12-?2013 14-10323 NCEZID I DIVISION potential airborne exposure BLDG 23 Employee was working with commercially purchased ESCHO OF SCIENTIFIC pooled sputum and handled at BSL2 in a BBC. A [Medgate-?WIMSI FIESOU RIDES I AFIB sample was requested by TB and they discovered DNA in the sample. No live organsisms were ever cultured. 0651232013 14?102?0 NCEZID I DIVISION Possible airborne exposure BLDG 23 Employee was working with commercially purchased ESCHO OF SCIENTIFIC pooled sputum and handled at BSL2 In a. BBC. A [Medgate-?WIMSJ FIESOLJ FIOES I BE sample was requested by TB and they discovered DNA in the sample. No live organsisms were ever cultured. cane-ems 14-10176 NCEZID I DIVISION exposure, no illness BLDG 23 Employee was working with commercially purchased ESCHO OF SCIENTIFIC pooled sputum and handled at BSL2 in a. BSC. A [Medgate-?WIMSI RESOURCES BE sample was requested by TH and they discovered DNA in the sample. No the organsisms were ever cultured. 14-10212 NCIBDI INFLUENZA potential exposure to TEL no illness BLDG 13 Employee was working with commercially purchased ESCHO DIVISION I OD pooled sputum and handled at BSL2 in a. BBC. A [Medgate-?WIMSI sample was requested by TB and they discovered DNA in the sample. No live organsisms were ever cultured. 14?10212 NCIRD I INFLUENZA potential exposure to TEL no illness BLDG 13 Employee was working with commercially purchased ESCHO DIVISION I OD pooled sputum and handled at BSL2 In a. BBC. A [Medgate-?WIMSJ sample was requested by TB and they discovered DNA in the sample. No live organsisms were ever cultured. cues-eon 14-10511 NCEZID I DIVISION potential lab exposure to M. tuberculosis BLDG 13 Employee was working with commercially purchased ESCHO OF PHEPAREDNESS pooled sputum and handled at BSL2 in a. BSC. A [Medgate-?WIMSI AND EMERGING sample was requested by TB and they discovered INFECTIONS I DNA in the sample. No live organsisms were ever cultured. ores-eon 14-10210 potential exposure to TEL no illness. BLDG 13 Employee was working with commercially purchased ESCHO pooled sputum and handled at BSL2 in a. BBC. A [Medgate-?WIMSI sample was requested by TB and they discovered DNA in the sample. No live organsisms were ever cultured. 01:10:2013 13?6091 NOEZID DIVISION needlestick iniury from monkey infected with P. Ialciparurn BLDG 23 Veterinarian was traristusing Aotus monkey which was n'preper place'rter'l ol ESCHO OF SCIENTIFIC Infected with Ialciparum when stuck with needle while butterfly rite sharps [Medgate-?WIMSJ BESOU REES AFIB disposing in sharps container. Discussed With malaria come he? branch SME- confirmed low probability of Infection. but patient treated with tvlalarone [2 tablets bid. 3 days]. Researcher confirmed positive rabies titer. During necropsy, as individual was taking the needles out ol the mouse's L-2322 This was labeled by the site as an "evenl', not an Event. not accident ESCHO POE Dan Browning ligaments she stabbed her second tinger on her lett hand when she went accident. so there was no recordable iniUry. nothing to pin the needles back into the platterm. No agents were involved. beyond first aid and no follow-up by the site. During Safely Otfice evaluated the procedure and directed the employee to use necropsy. as individual was taking the needles out of the the proper procedure. mouse. she stabbed her second finger on her left hand when attempting to pin the needles back in the platterm. No agents were involved. Safely Office evaluated the procedure and directed the employee to use the proper procedUre. NCEZID DIVISION OF drank water; potentially contaminated BLDG 13 The researcher was In the Fleptiblic of Georgia and Exterrtri exposure ESCHO HIGH drank water from a stream. potentially contaminated Iwith CONSEQUENGE Leptopiria so. SIVIEs did not recommend treatment PATHOGENS AND without Titers were drawn and found to be PATHOLOGY I PFIB negative for Employee was contacted and case closed. 2 5 DFIAFT - Hot for distribution - may contain sensitive invorrnation or factual errors. Clinic Lab Incidents - Selected Incidents POC Dan One lliEl? glass bottle containing 5% l0 20?51 nitric acid cal sjurage Pr?gram Brownmg espen?enced a violent release Of its contents due it} El Subn?u?ed build up bl pressure. Debris was mostly inside the chemical fume hood but some material projected outside the need. No injudes. Acid cleaned up by site personnel. Outcome: Lab was directed to write an SOP tor ho n- routine waste. Saletv Ottice purchased No injuries. cleaned tip by site personnel. Outcome: Lal:r was specialty pressure relief bottle caps to ensure all waste Tr'l 8:201 3 Morgantoim directed to write an SOP for non routine hazardous waste. 2413 bottles will not over pressUrize. PUG Dan Employee was changing out the formalin {4 liter] from the Program Browning tissue processor. Later noticed was irritated. DUrlng Submitted the transfer the employee splash ed some in their eye. Outcome: develop an SDP fer the tissue processor; utilize safety,r glasses [with side shields) or goggles; NIOSHFHELD Employee was changing out the formalin i4 literjr from the tissue doubleI glove or change gloves frequently: use a small li'31r'2013 Morgantown processor. 34158 more stable funnel. POC Dan degree burn via autoclave. 313 1st degree burn via autoclave. No medical attention. Program Browning Pittsburgh Site first aid. Corrective Action: Instructions to use Submitted insulated gloves [already available] to load-'unload 552852014 autoclave. POO Dan Laceration requiring 2 sutures at hospital. Employee dropped glassware 83? Laceration requiring 2 sutures at hospital. Employee Program Browning Pittsburgh while attempting to apva rubber stopper to glassware. dropped glassware while attempting to apva rubber Submitted stopper 1o glassware. Glassware broke on lab counter top and began to fall to floor. Employee attempted to catch broken glassware. cutting hand. Corrective Action: Instruction to use lubricant to reduce lrictiort when assembling glassware and cautioned not to handle broken glassware wi'o proper for clean Lip. POE: Dan NIOSHIOMSHH Dunng an air arc gouging {welding} procedure to generate noise tOr an Outcome: is evaluating the procedUres and Program Browning Pittsburgh experiment an employee believes. she was exposed to elevated levels o1 sampling for contaminates. They are also working with Submitted metals. an Oce Health Physician to ii there was any work-related exposure. has reviewed all therr safety.r and health procedUres. audit processes and training programs focused on improving safety. 153 5 DRAFT - Not for distribution may contain sensitive invorrna1ion or factual errors. use. a Program Lab Incidents All Reported Incidents 262athi (bjit3jiz42 use. 262athi Date- Injured Medgate ClOi?Of?cefBranch De Description sate?: 262at?h) Building Description Incident description Comments Information Source Lab Name :i 03:01 4- PROGRAM information 262athi bj?3ji42 August 2014 - ernloyee stuck her tinger with a broken glass capillary containinaccine [Squibb]. Employee checked the glove for tears'a'nd' could not find any. She washed her hand and iihger thoroughly. She was unable to express blood. Employee teen reported incident to supervisor. Supervisor noted small abrasion to the finger advised employee to go to the Occupation Health Clinic. a it" lini employee scrubbed the area for 15 minutes with betadine. was able to see the abrasion. but it did not look like it penetrated the skin. A water check was performed on all gloves used during processing of this sample and no gloves had been compromised. Out by glass containingl Ivaccine 262ath) Ute-"es were "o1 sen usc.? 262ath) It. PROGRAM information DSR - Equpment which was intended to eventually be ex cessed was removed without necessary decontamination documentation. Equipment retrieved and no infectious age his involved. No exposure Recess prope' It. PROGRAM information DSR 1?25-?2014 - Finger laceration on door kick plate. One individual sent to CDC Occupational Health Clinic for evaluation and treatment of lacerations. ?3:131:42 U.S.C. 252mb} [b][3]242 U.S.C. 252mb] use. egoeatnj cram-14 PROGRAM information 2514:2014 Laboratorian a torn glove ll "iihaitced space. Not a I serious event. i?I? Td'r'f't' glove Git-"09H 4 PROGRAM information DPEI Sublect was working on a flooring replacement job irl involving two procedure rooms and hallway previous - [with H202 and peracetic acrd]. Repair person punctured index finger on his left itarid with a piece of glass while installing new I Worker had been told to wear gloves priorto begining work. Subject was' not wearing his gloves when he cut himself he states that he needed to remove them to perform a specific task and had taken them off only for that specific purpose. Subject states that he removed the glass and threw it In the trash can. cleaned wound site with the hand sanitizer and resurried work with gloves on. Subject reported the the following morning An incident report CDC form 304 was completed and the subiect went to the CDC clirtic ori OSHE arid OSSAM were contacted and a report sent by OSSAM to DSAT to determine if any other actions need to be taken But: not wearing required PE .?2523ihj: 252athj: inj:i3j::42 use. :42 use. a 252a hi ibj:r3;::42 use. a 252arhj: Eff-"03? 4 PROGRAM information FIB fin oer freezer burn by a rack in LN tank 23 Burn from LN 4 PROGRAM information Technician was plating Elartonella henselac and Bclarridgeiac in the lab to make aritrgert an I scraped my right index on the hood handle . The tech was removing her hands from the cabinet and began to turn left. her rigitt hand came in contact With the edge of the stainless steel handle torthe sash. The impact had enough force to penetrate the nitrite glove and cause the laceration. 61 ?ltFort lCollins] But from BBC sash ob Mass Ll ng Barton ella Lab PROGRAM information Employee was working with equipment used to grow E. coir ATCC TUDQEE 1i. Whil? disconnecting sections of tubing. he received a srriall splash to the face near the left tbut not in the eyei. Erripleyee was wearing proper PPE at the time. He immediately removed gloves. washed hands. removed glasses. and washed his face in the lab sink. He took a shower in the Building 1? locker room and than reported the incident to his supervisor He was interviewed in the CDC Clinic. completed the incident report and was released without treatment after a baseline serum was collected. 2&14-1Ui 1 Disrnantelrng of eourprnent for use with E. coli caused a splash to the face ti'eat'rmt 'ieerlerl 'v?il'ea' rig p'opsr PPE: no Judith Nob ang Clinical and Environme rital Lab PROGRAM information CG A DPDM employee slipped on water in the hallway and song hi treatment one a 9 cm ibj:i3j::42 323 to on hallway il-s-o- er. "ace Ace dent d..e to quie or a Program Submitted PROGRAM information DPEI Potentialrelease of .- i pace: extracts. possibly contairiirig viable spores were pip i I- - well as. material was transteryed 1o laboratories in Proper notiticatiort of ESCHCO occurred on Q?ft 35.2014 Multiple 'Ii [bit-331342 user-s 2e2arhj: I . . - personnel are under medical surveillance by CEO clove. P?l-?l ll?sans..re (bit3id sass (bjit3ji:42 use. 262ath inj:i3j::42 2e2atnj: use. 262ath) radii-512 use a 2 62a (were so. a 2E2ath) atn] 252arh) (bif3ii42 zezathi DRAFT - Not for distribution may contain sensitive invormation or factual errors. Program Lab Incidents All Reported Incidents use. use. 262at?h] - PROGRAM NCEZID: DSR Era-'14 Sill-'14 Release ot . to . Several I Emil Itxoes..re I information individuals [13} were and were ottered proph taxis-immunization as ad ro note. This links to other safet I noticing reported by . iblt3l142 UE-C- 2.62am) zezath :5 262a (ctratzatzesc. uses rename-o 3'rl2Ll so a 262alhl 262ath) 252mm i ll l- - - 262ath 05:21:14 PROGRAM DFWED 552152014. Laborotory PI was internted that one of the cameras in I I Camera malfunction due to light Repaied information was not functioning property because at interference the light. Both cameras were replaced on 1?2-?2014 Following the .rr' repair. lreguested a written document that stated that the new cameras U.S.C. ?j2?2aihit were checked and verified to be functioning correctly but have not Qagamj received that. This issue is unresolyed beeatise JCI or an electrician has returned to this unit several times since the cameras were replaced in ., a ., July. 2011. Since there has been no change In the lights in the walk in 252am" since this reiterated Unit was installed in 2001. then I presuine that the interterence identified just this year also was present in 2011 and and yet 2" 252 ha I I I never recognized nor reported to the Pl. may? use. 2525? .. U- 3t .- USO. EEZath; ?3:133:42 30 252mm PROGRAM DPEI Poterttlal reduced aIrtlow irtl was observed when Airflow reducedl information window slot in doorto anteroom was blocked (05:2014]. PHOGHAM 4-?16-?2014 Fewer outage caused both air handlers and air exhaust to 23-"4th - all labs Fewer outage caused shut down of air handlers-Exhaust eyacua?. 3?1 CVDB information shut down simultaneously resulting in potential air ?ow issue in the lab corridor. Evacuation followed instructions Issued by loud-speaker announcement 04f15i'14 PROGRAM DSR Processing of sputum that was later to be determined to I323 5th floor sputum expsoure tuoercclosis expsoute of Dennis Bagatozzi Scientific information contain Myco bacterium tuberculosis. Sent 5 personnel to clinic tor 5 aersons Products evaluation and Support Branch 04f15i'14 PROGRAM DPEI Four people handled trials oi M. tuberculosis-containing sputum in BBC. 131633505 sputum expsoure Brad Bowzard LPREtiBuild information No work was performed outside HE C. All four individuals participated in ing 13 Lab medical surveillance at CDC clinic and had TB skin tests performed. [D4i'2014]: please note that this one links with the incident noted on the 5th floor ot hldo 23 on 4r'15r14 PROGRAM NCEZID: DFWED Indivdual was opening a vial of antiserum trial and sustained 23:? 551 Cut I23 p'c prescriaec Matt Mikoleit Enteric irtforrttatiort art rttIrtor cut on the thumb l11fttEdiatBiy washed itartds and went to the Diseases CDC clinic. The doctor thought that since the indiyidual was also Laboratory handling iterris that had touched the lab bench there was a rrtinirrtal Branch that they could have been contaminated. Dut ot an abundance of caution. the dectsiort was made for indiyidual to take ctptofloxaciri prophylactically Get-"05514- PROGRAM NCEZID: byeo Technician was in the lab ma nipulating litre chilled fleas with force s. F'unctured gloves with information The fleas ttad beert__p'teyfiouslyuexposedto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Aiier"l"ha'd'fi'r"iistied working with the fleas and had secured them in I 262mm closed trials. Iwas rttoyirtg the forceps and accidently punctured my right 1.5 indett finger through my gloves. The forceps had not yet been disinfected te skin I may therefore have been exposed to. 2625mm 5 .Ishe was. picking up an empty petri dish with her right hand I at the same time as up the forceps with her left hand. when site was lifting the petri dish. she did not notice how close her indet-t ting er of right hand was to the sharp ertd ot the torceps that were in iter left hand. 2 33-2015 iBit?iEt? BEE DRAFT - Not for distribution may contain sensitive invormation or factual errors. Program Lab Incidents All Reported Incidents [13:31 4 PROGRAM information NCEZID: DFWED Improperly packed isolate shipment trom a state received In our otfices {via regular mail instead of usual laboratory package drop- oftjt. The box [a used cardboard Remel media without any additional contaminant] was partially crushed. there was a hole in one corner ot the 130K. and one of the tubes inside was open or broken. Our laboratory team members who received the package and appropriater followed the ste ps tor package reiectton trom our approved OMS procedure on specimen management By comparing photographs ot tops with the shipment manifest we had already received electronically. we were able to confirm that no tubes had tallen out in transit. Consultation trom OSSAM experts was swift and helptul. Our team members who handled the package reperted to Occupational Health Clinic that day. and people in CD8 shipment receiving were also notified After confirming [with the help of some forcepst that none of the of Salmonella Typhi ap pearod to be broken or open. the entire package was autoclaved as biohazard waste Subsequent shipments we've received from this state have been in better condition. but not tully compliant with IATA regulations. We have not yet received a CDC incident report yet for this. Salmonella Typhi shipped from state improperly; state still is not shipping by IATA regs no or Eff-0?11" patJrJ. doc-?age attoc avee .Jean Whicha rd Enteric Diseases Laboratory Branch 0351 3-"1 14-9851 DSR OSHA-2014 Medgate #14-9851 ?5 ip and fall. Individual fall when her laboratory stool rolled away unexpectedly; stools do not have locking casters Individual was sent to CDC Occupational Health Clinic for evaluation and treatment. ESHOO attempting to find sourcing information for locking casters Stool caused slip and tall Seen rig getting COST-DIS Sift-U Dr Joseph lgietseme Molecular Pathoge ne sis Laboratory 03:12:14. PROGRAM information DPEI Clinic visit for cut on tittger trorrt scalpel to open a package instead of scissors. [03312-2012] 18-8313 505 {lut by scalpel: use of scalpel St; was shot. "ave deert used to ope-n damage- Brad Bowzard ing 1 Lab 4 PROGRAM information (13113) 262st h) FIB 42 March 3. 2D14 - employee discovered that both his inner and outer gloves tore while moving cages that Itoused__ ntected prarie dogs. Skin was intact aadultherewas'rttitiiloo an area did not burn when spraye chith-eth'a'r'i'ol. Employee used the betadine scrub in the bites'b'tiitch kit and scrubbed the thumb tor a full 15 minutes as directed by the kit instructions Emlo ee re oned incident to supervisor and had the area examined bin PRB. No evidence of skin disruption was observed. March visited the clinic for additional observation of the area and clinic confirmed that the skin was not compromised Form 3 submitted to the (bits-r42. 252ath) zezath) Torn gloves ski" tick-art :crrt salt-rinse u.s.c. 262ath) ?it 262ath) 03:13 1 4 PROGRAM information Mar 2014 - A laboratorian within the lab accidently splashed with ice from a thaw1 rig freezer because she was not tollowing safety procedures [i .gogglesi. Retraining is currenlty underway to ensure that staff are a masts-q aware of all appropriate [1331 .1342 U-S-C- 1.7" b::[3::242 U.S.C. 4 52am} Improper PPE [googlesi cause splash to [1138142 U.S.C. 2523M: Reba it rig P31: Cathleen Hanlon Rabies E1251 4 PROGRAM NCEZIDJ Laboratorian experienced a torn gtbi't'e'lt?! lenh anced space Not a serious event. Torn glove irI 1131131: 42 U-S-C- . 4 us 262aiht PROGRAM information (b NCEZIDH DFWED 2a{h) may. zszath) Zia-2014. Potential security breach during pass-through autoclave maintenance: autoclave door opened menu It in nn- -mewhen door in registered space . notified by entail on 256. investigation - and HG olfice. additional trainntg (bjt(3jt:42 use. a @ovided'to'bb'iit program statf and maintenance staff. Final Form 3 report submited to DSAT on investigation closed by DSAT. Outstanding iSSue seems to be the fact that a pass-through autoclave could be opened manually [both doors;- trom the non registered side provides a potential security vulnerability into the SA registered areas. 2 idiot-:42. .5 zezath) use. Potential security breach ot autoclave into non- registered space .c Li .3 . c. 2s2aih) r. (131131342 USE- 3 1'0'113. suart' tied: Autoclave L-e cope-tee tnattJa ly sle'c side Outsta-?d ng 3.: Iii-1113111? 2623(111 0250431 PROGRAM information on 3Febt 4 was extra primary samples were plated an bacterial growth media i [12:01 4 PROGRAM information NCEZID: DFWED t. I. February 2014. 1i'lJater leaks in ceiling-"mold in I discovered mold in ceiling of storage room and more WI O??ni?h?t 262ath) Samples received. laterl I .reported trom patient (Maytagst WELT-.1 '35 sr' . i-ify I 25251 {btt3tz42?'1' 50855? to assess and repair._ceiling. Water leaks-'mold [b38142 use. speeding: I t- Jtii-i-SS and 1?13 Kevin Joyce Enteric Diseases Laboratory Branch zszarh) [1113:2312 2523M: [1113:2312 U.S.C. use. FT - Not for distribution may contain sensitive invorrnation or factual errors. Program Lab Incidents All Fteported Incidents 12:29:13 PROGRAM DPEI on Thursday. Dec is at aE?Ergx. to am, two laboratorians entered the I Potential leak on tra?ii' of] I [0'11 3. sum .S.C. information located inside the biometricall [t ?3342 2525'? 262mm (mtg) 42 Their purpose was to transfer nietaICDC discard pans to the I 262a h) f_ autoclave tor sterilization. The metal pans are lined with plastic bags and ?Lrl contain 250 mi of orthophenyl phenol {CiDeco n] disinfectant in the pan's 2E2a{h) liner. The pans were sitting on top of disposable absorbent diapers outside of BBC containment following proper surface disinfection {10's bleach]. The diaper below one of the pans was observed to contain a moist at of less than 20 ml of ti uid that ossibl had leaf-ted from one of the plans. The pan was immediitely placped inside a new larger discard 262ath) pan The diaper with the leaked liquid was folded and placed in a ziploc bag. which was then placed in a discard pan. The area beneath the diaper was disinfected immediately by saturating with freshly prepared 10% bleach. The larger pan and ether waste were Immediately 252E autoclaved. The discard an had been used while working with the Tier 1 agen? It is unknown if the lealt was only disinfectant or bacteria disinfectant Form 3 was submitted to DSAT. No ftirther actions were required by DSAT. 11:20:13 PROGRAM NCEZID: DVBD fellow was exposed to unexpected chemical fuines during room 32-13 Fellow expsoed to unexpected chemical fumes investiga: e" and disease information laboratory work. and developed irritation after getting home. The recommendations to to low ecology incident was reported to the supervisor. branch chief. OHS Clinic and aspen: so- director. and safety officer. The fellow was seen by the occupational health clirtic. referred to a private physiolari. arid treated. issues resolved over time. The incident was investigated by two members of tire Safety office 013} and recortiniendations provided to the fellow and her .b 6 Sit 1-?2013 and PROGRAM Got a little eporiy resin in left eye. epoxy in Goldsmith IDPB 101332013 information Between 9:11:13 8- 11:13:13 03:25:13 PROGRAM 9:25:2013 Biochemical spilled occurred when a waste tube detached 23-"4th floor Spill: contained: disposed of properly No exposure Martin Steiriau information inside the automated line blot hybridization instrument. Approximately 4.71 [3229] 250?500rnl of waste liouid leaked inside ttie instrument and spread ortfo the workbench. a wall and the floor. As the incident was not observed. precise wash step and chemical composition was not clear. Based on bluish color. it was concluded that and substrate solution were in spill. Laboratory staff rtotified their supervisor. the branch delegated safety representative, and ESHCD as soon as spill was noted. The spill was contained and all material in contact with the split was disposed in a container from the chemical spill cabinet. No persoriel exposure occured. 09:23:13 PROGRAM On September 23. 2013. laboratorian hit her head on freezer while Head injury front freezer Not a se' o.,s Seales ARB information defrosting. which caused some bleeding btit was okay by the time she animal gal ta the Clinic I'm 03:23:13 PROGRAM DSR - Finger Joint pain and swelling due to shelving products. Onel -- 'S'oie tinger:'ioint due to shelving products Not :3 cc o-s n_L 'y information individual sent to CDC Occupational Health Clinic for evaluation and ?gamer?- (bits) rej:i:j::42 use. a 252a_i_i_1;: 03:03:13 PROGRAM On 3 August 2013. a sash of :3 BED fell on a employee's foot. 323- 9-431 In "'"Iissued a retrofit of this particular p'no": sstic? caLisdd Program Submitted information The employeed sought medical care with a broken toe. 350 line to provide two metal clips to stop the sash from falling should the counter weights brother safety measures fail This was not issued as a "Safety Notice' or a "Safety Recall'. Due to the El years that elapsed between the notification and the incident. it is unclear if CDC was notified or it they were notified. what action was taken 03:01-13 During necropsy. as individual was taking the needles out of the L-2322 This was labeled by the site as an "event". not an not acc d-enf ESCHO POC Dari Browning rriouse's ligarrients she stabbed her second finger on her left hand when accident. so there was no recordable injury. nothing she went to pin the needles back into the platform. No agents were beyond first aid and no follow-up by the site. Dunno involved Safety Office evaluated the procedure and directed the necropsy. as individual was taking the needles out of employee to use the proper procedUre. the mouse. she stabbed her second finger on her left hand when attempting to pin the needles back in the platform. No agents were involved. Safety Office evaluated the procedure and directed the erriployee to use the proper procedure. 03:01:13 PROGRAM NCEZID: 3 Individual noted significant irritation when in Building 23. 23-?4-1 10 irritation re?c?rec to Irina Dirnulescu OVDB information are relieved when she leaves She contacted the CDC clinic tiad??: when the persisted. 4 33352015 DRAFT - Not for distribution may contain sensitive invormation or factual errors. Program Lab Incidents All Reported Incidents PROGRAM information NCEZID: DPEI laboratorian trom BRRAT Lab came to the RAST lab to use the shaking incubator for coli cultures-plasmid preps. The large flask of culture was not properly secured in the shaker. came loose and broke at some time during the incubation RAST lab staff assisted the BFIRAT lab team member to clean tip the spill. No injuries occurred. Alter dissussion with Branch and BRRAT lab leadership. RAST team lead requested that no BRRAT lab staff work in RAST lab without supervision by a member of the RAST lab staff. 1 improperly sealed container HAL-E Int: stat! wt supe'? se external lat) perso'inel when sorrow ng ecu p-re-tl Linda Weigel RAST Lab PROGRAM information DFWED Individual missed last step when stepping on a step-stool. fell backwards and hit her back on a metal trash can. The event was witnessed by two other statf meembers. Individual went to [he ccupational Health Clinic and filed an inctdent form. She applied ice to the affected area on her back and returned to work the same day. No further medical treatment was sought or needed. 23-71531 Trip and fall Net a se- n..s Nancy Enteric Diseases Laboratory Branch 3 PROGRAM information 3 Lid of safety carrier In mid size centrifuge came ott at speed 20mm and shuttered inside. Raters held 50ml Falcon tubes containing 10ml buffer only. No broken tubes or leakage occured. 23." 4th floor Rm 410 samples Lid in centrituge came off: butler only: no broken Nc Gitika F'ariic ker [dhv CVDB 3 PROGRAM information DID 1TB SterilGARD WEEDS In the manufacture re issued a retrofit for for the the dos-e03 3805 The retrofit was intened to stop the sash trom falling should the counter weights or other safety nteaswes fail. When in 2013 we did have a sash fall it was discovered taht the retrofit was never applied to the BSCs that we had on campus. Butlding 23 required for equipment BBC sash equipment issues: BBC manufacturer retrotit I:cu p'ne': ssue caused itjury Kathleen Keyes Ltd-"13513 Case #1 3-5611 DFWED Individual dropped a scalpel on their foot The skin was not broken but a "little bump" developed. Evaluated in CDC clinic. 11-2121 dropped a scaple on foot: skin not broken No esoossre Shawn Lockhart Mycolic Diseases Branch 3 PROGRAM information Performing microneutralization assay for 25 samplesFipetting using multichannel peppettestots of pipetting had pain in left hand and could not complete the last part of the assay.Following day "my hand was Swollen and in strong pain.Wen1 to doctor who prescribes anti- inflammatory drugs. physical therapy andone week of rest. [San Ju an] pain in hand: RX and physical therapy Ne Rob Mass Li rig Dengue 3 PROGRAM information Stag-"2013: Laboratorian esperinced space suit malfunction in which a tube feeding breathing air into the suite detacted No exposure determined. Suit maltunction ?3:13:42 US C. 252mm Ne 3 PROGRAM information DH DP Employee scraped knuckles and cut finger on freezer rack when it slipped while transferring freezer boxes from one metal rack to another. Freezer boxes contained vials of frozen Staph aureus. Employee was usirtg large irtsulated gloves to transfer racks but gloves were oil when the tray.r slipped. Hands were washed with soap and water. then sater oilicer and supervisor were notified. Employee was seen at CDC clinic and cut was bandaged. Employee was instructed to wear clean latex gloves urtd er heezer gloves and to work With another person when transfc ring treezer racks. (NICE 2013 It] 1 ?-"4245 Scrape and cut from treezer rack containing Staph; not wearing gloves when tray slipped Wn? . war-r. pai's when hammer? freezer racks a ew Ardutno Clinical and Ertvironrrie ntal Lab 05513313 PROGRAM information DSR Several individuals have slipped but not tallen due to frozen condensation ll'l walk-in retrigerator. Bucket temporarily in place to collect. and no iniuries reperted. iv'latter unresolved: FSE still working on problem as o1 Eta-'1 5-2014. 23 11-409 Slips assuring from condensation in walk-in nc i"i..ries. rig issJe Dr Joseph lgietseme Pathogene sis Laborm 3 PROGRAM information NCEZIDJ DVEID Flea count revealed possibility it a missing single flea that may have fed on an infected blood meal: corrective action (bii3i:42 use-fa 252ann 2E2aih) .I Missing tlea 3 PROGRAM information NCEZID: DVEID tvtissin flea when makin final count at the end ot standand procedures using The missing tlea is believed to be lost due to a counting error in the clean insectary or during transport because the tubes were carried horizontally instead of vertically Fleas that may get on the inside lid can be propelled oft the lid by static electricity. No loose fleas were seen during the feeding. Nobody was bit by a flea and everyone was wearing appropriate allow for exposed skin. Finally nobody was exposed to 5 by any other mode 3'1 262aihi 0336342 . .. 262aib} Missing tlea; possible counting error: no bites: no illness Exacs..re based 0' SA as and nterp-etation usc. 262ath 262ath FT - Not for distribution may contain sensitive invormation or factual errors. (bysy42 252aih) zszathty 3 PROGRAM information NCEZID: DVEID Working in a biosafety cabinet etitting a?marine mammal uterus psing a scalpel the blade slipped and cut her double?gloved hand was very minor. btit she was able to squeeze a fetiy drops of bloodi?from the cut after she removed Iter gloves she washewnd the bleeding quickly stopped. she resumed wort-t.? labpratorian cut hand with scalpel while working with a marine mammal tissue. Sample of the tissue was tested and found to be negative tor OHC put employee on fever log. no developed Program Lab Incidents All Reported Incidents tbtp3y42 'r trance luse. 2szaihi BBC work; cut with scalpel. punctured double gloved hand l-eve' cg: no 0550151 3 PROGRAM information NCEZIDH FIB May 2013 - Rabbit {#35208} on li?tCUC protocol #2333 inoculated with raccoon poi-t for produ mien o1 hyper-immune serum scratched employee. Scratch present but no blood. Supervisor was informed and employee visited the clinic. Dral swab from the rabbit was taken: restults confirmerd that animal was not shedding virus. Employee's temperature was monitored twice daily ior 2 weeks. New safety measures were implemented to prevent future incidents. Ky I [1&0 Scratch. no blood 2523M: Si?t?lL?Ty' [b13142 3 PROGRAM information May 2013 - Rabbit {#35203} on li?tCUG protocol #2398 inoculated with raccoon pot: for production of hypfer-immune serum scratched employee. Scratch present but no blood. Superyisor was intormed and employee visted the clinic. Gral Swab iron'i the rabbi was taken: results confirmed that animal was not shedding virus. Employee's temperature was monitored twice daily ior 2 we eI-cs. New sfatey measwe Scratch. no blood 05501 3 PROGRAM information it?) 26:!ath) tbtt: L42 use. 262 (MB FIB 3M2 Lte-C- :42 252a ht 'J'tr'iimatwasscreen for previous Bartonelia athogen screening. Animals status tored. New sa measures were Implemented to prevent May 1. 2012 - employee bitten by an uninfected prarie dog while transporting the animal between a tub and a scale for a weight check. There was no in the glove or blood Visible. Later. employee checked the area and there was no sign of a bite. no redness. pain. or blood. On May 3. 2012. employee noticed a bruise on her finger and of the area noticed 2 small punctures On May 4. 2012. employee and visited clinic. Employee was provided a provided tirst aid supplies-[band-aid and neospoiin?i at clinic. Ne satet m-aaeres 13? future incidents ?nimal bite N-J Eatm'y i-rp e-i?e-itec use. 262athi 3 PROGRAM information NCEZIDH DVBD Tube broke which contained infected mosquito parts ground up in media. It was not apparent the tube was broiieri until Imoyed outside the 080 at which point lsavv media outside the tube. Testing of this sample showed 6:10 4 of Chihungunya iv'irus. Risk of exposure was through inhalation of aerosols as I did have gloves and lab coat. The mixer mill seemed to break ott the 2 0ml snap cap during the mixing-grinding process. The cap appeared to still be on prior to movement outside of primary containment but after physically picking up the tube. it wasnoticeable that cap had been sheared off. Possibly the force of the bb inside the tube that helps the mixing process may have broke the cap.alter much trial error . it has be determined that this tube type works best for this min-ting procedure but a weakness in the integrity of this specific tube may have been the root cause. Collins] Tube broke with Chikungunya (bii31242 LLB-C- L'J-ete'wti'ce app-cp- a -: elec'. 1'1 speeitie tube used 'i'.11 IS 'i?ist itg ike ii,- Rob Mass Ll rig AD 3" Ecology! Entomolog ibiisizce use. a 3-12-2012. dry-"2013 PROGRAM information DVBD Flea feeding system developed micro-crack and potentially infectious blood to teal-i into circulating water bath. 0351 1:1 3 PROGRAM information i Mir-n. DSR 62ath) by iiriperted NHP prior to coming to CDC. Potential - non-hurtian riritate beiri held for future research at EDI: diagn infection. Infection exposure to animal handling staff mitigated by CDC Occupational Health Clinic euthanized and ito infections or seroconversioiis in those ootentially exposed. tiea-t-eeding system micro-crack 262ath .. lose. a 2szaihi 0252331 3 PROGRAM information tblt3ii 262st (b 26 NGEZIDE FIB 1} i3y42 2a{h) February 23. 21313 - employee stuck her I I . eedle while dis using of a needle after euttiarinizing infected prarie Employee immediately removedod er 9 ove an discoverd a hole. primate with potential exposure to stafi 252aih) Ne i "ess occureo ?'ci't perenta csoos..i'e (til mp eyes then retreiyed kit A water tes1 was done on the inner glove ands-hole discv overed. Employee then placed th Umb under th?water'and alternated between rinsing and attempting to express blood for appro>iimately 3-5 minutes. No blood was able to be expressed Employee then used tiie scrub that is in the hit and scrubbed the thumb tor a full 15 minutes as directed by the kit instruc1ions Employee contacled the Branch Chief and was escorted to the clinic. Clinician utiliaed magnifying glasses and lighting and was unable to locate a wound. Eriiployee was put on a tever log and post exposUre levels tested. Form 3 submitted to the R0. New safety measures were implemented to prey ent future incidents. Needle stick Form 3 sLib-i'i New saier me i'i'p e'r'e'itec tb]t3]:42 use. a 252a FT - Not for distribution may contain sensitiye inyormation or factual errors. Program Lab Incidents All Reported Incidents use. Iii-30s 02.21313 PROGRAM NCEZID: DHUPP 2:21:201'3'. Laboratorian experienced a space detect. but was not in Stilt malfunction Ne measure information a containment enyironment. iinj:i3 :42 use. U.S.C. size-eats: I 3 :42 use. use. (235.6101) tb]t3]:42 so. 2E ibii3l142 252ath) .. zezatni 02520313 PROGRAM DVBD Paraffin was melted in a plate. Th'e'f?i'tt't'pl'a?teouer -- Sp?Il of hot paraffin: gloires reinoyed rip-rope- 'eri?c-yed PPF I I Liar; information heated from set temperature. Paraffin and container was being remot.I ed 3 with heat resistant gloves. The container slipped from gloves and I: spilled. Gloves were remoyed and container was totiched with bare [b][3]242 U.S.C. 252mb] 262afh) fingers accidentally 2-"1 1-2013 Laboratorian experienced a Suit detect. No exposwe. ISLiit malfunction Ne exonerate I .. information U.S.C. I 1 I I 02:12:13 PROGRAM noezror oyso boralorian burned finger while heating paraffin. . Burn . U-P-P- 8' use. many-m? _fl (WW-42 252ath) 2S2afh] DPDM laboratoriah cut their finger on a scalpel while trying to remoye 323 till 641 But ibiafnj II Program Submitted information or front a 1.5 ml epperidoif tube. Employee sought treatment at itLioeji LJ so. a . . 262361) 03-05313 PHUbt?teiyi Notaiuf'ffr?da?i [released a lot of ._illautoclaye released steam into lab corridor a.iti:ic -epai-ei:l information (b38342 steam into the lab corridor. This se he hallway triggering hallway sprinkler (bust-42 a mail ire period - - action - yaw ii into -- .30. (bll3li42 .. was repaired. I I 252aihi 262afh} 262aihi PROGRAM ?3-?2ffiI?lI3. Individual had a reaction while working with liquid nitrogen and - 23-"T-Lab Corridor reaction: ?person has allergy to cold temps reocced eip-lj-E-Ll'e' aetiyi?. Nancy Garrett BEIC freezers. including tingling and swelling lips. Indiyidual was LER 1? DOT assessed at the CDC clinic The diagnosis was allergy to cold temps. 3 3 -42 3 Individual now takes measures to reduce exposure to cold temperatures. I: I I 2E2afh) including not working around freezers alone in case a reaction happens 262mm again. PROGRAM DVRD Strain injury to right hand. ring finger. Deeured in lab 4-122. 4Dfi'4-122fFort strain to hand oorso'ia Rob Massung Virology information while opening freezer door Previous hyper-extension injury to same Collins] hand - 3 years ago. Cit-"14313 PROGRAM NCEZID: DHUPP 8th finger with a razor blade. 13.33212 cut Ne measure Goldsmith IDPB information No infectious agents involved. 1314520113 01511313 PROGRAM DPDM laboratorian Cut their finger while trying to stabilize an oft-balance 323- 10-641 Cal 'I'on? Iati saviour-ant Program Submitted (bjf3jj42 information centrifuge. Employee sought treatment at CDC clinic go: .. Door to Serology Laboratory would not completey close unless pushed ?int-'2 airflow issues [1 1 incidents, all addressed by Geo? "ot closet; Kuehl MVPD Information ., requesting regatta by F5- personnel'i Fleetirring PROGRAM DVBD ati autoclati'?'Lbften has an Where the No exposure Fcu p'fie'?. Issue resolve?? information will not open after a completed run. Recent work has been U.S.C. (b]i:3]j42 252aih? done to try' to fix the problem. It is currently functioning properly gg'ga'f?j zazacm . - Recurring PROGRAM Ei 425-ECIU series BSCs were found by lab staff during a root Ecu tyne-'1 Issue Kathleen Keyes information cause analysis to be incorrectly certified by the contracted seryice - technician to the wrong specifications 2012] I 5_ (bj?gj?z 262ach i. 1-?31-?2014 Program ID Cut hand on door placard, resulted in bleeding tno infectious agents I Pht'Sica' injuries in lab areas {9 incidents] Door :ut halt: I If?mrmm'm presentt, reported to occurred on in currently reported to SA RD, follow up still under introstigatiortg '5 I 3 :42 Isaac. .. Ezegaim tb]t3]:42 use. zszathi use. 252a I 5- use. 3 2523f?) 262ach (b)(3)i42 262afh) DFt?i FT - Not for distribution may contain sensitive invormaiion or factual errors. Program Lab Incidents All Fteported Incidents use. 262atht use. 262ath] 262cm] [3 42 252a[h I I 6-?4f2013 Program In Clinical sample'l'atiie?ed'as - ithc?tEldlY also co-infected I I Use of inadequate safety level [2 incidents] mole labeled ?3.13.1342 U-S-C 252307} Information . inside a BBC as co?intect _I_.ising goo labora practices. Incident resulted in protocol changes Proscreen rig to tar UISIC. - coarsening-to I for future clinical samples from countries where 42 future 6' cal salt-1968 is endemic. Fte mod to DHC. SA form 3 was tiled. Form ft filed 252ath) E- 262ath] tottatz42 262a 262ath) ID Needle stick during rnceulation of mouse lungs with mouse- Percutaneous Injurvf' potential parenteral Need r' .?itick Stevens lF' adapted H1N1 virus. Reported to OHC. The laboratorian was inoculation t5 incidents] 252ml?) instructed to track body temperature in followup period, turned temperature log over to the clinic 2-?14t2tl?l4 Program ID F'erson Iell out ol moving chair. bruised wrist. Chair was subsequently 1Ti'5123 Ergonomic injuries [5 incidents: all reported to Fall trom chair: chair Stevens IP Information reoa_ired. reoa_ired Program ID Facei'eves exposed to aerosolized iCe from freezer; reported to 115245 Physical iniuries In lab areas {El incidents] Aerosol sea ice exposure to Kuettl IP Information DHC fac_. _,es Program ID pink?. finger broken in slamming dam investigated, dgor was 1.7.?5255 Physical injuries in lab areas {9 incidents] Den 5 a-nmed. b-olie-i Stevens IP fitted,person had surger'vtotixbrolrenfingcr ?manual?: dial-"2014 Program NGIHDF ?3 Stabbedfpolted hand with clean mouse necropsy scissors; 1752?!) Pht'SiGal inlUfiES in lab areas {9 Cut with Stevens Information reported to DHC scissors Program Building IacilittiI workers were propping laboratory doors open will'i Iheir ITFB Restricted access issues [4 incidents] Improper door use Haynes Information tool bags 33152013 NCIHDF DVD Researcher got a papercut.r reported to tetanus shot. trill-"litS "1 lab are-35 {9 Papewut Havnes PP administered Program Waste was improperly discarded stored [pans were overloaded}. 1?:?6065 Incorrect implementation of established safety Impi'ope' wasp storage.? Hagnes PP Information prUCedures wio exposure [15 incidents]. All addressed issue In: is by retraining of staff. November 2013 Program DVD Fan motors in the BSCs momentarily turned off when the light or the Equipment. BEG. autoclave failures [15 incidents. all Fqu pmert - REC "an Haynes PP March 2D14 Information switch tor electric outlets were operated. bv reguesting re pairs] mcto's Program Laboratory blue gloves were found in general trash. 1?:?6123 Incorrect implementation of established safety Incorrect dispcsal of eves. Hagnes PP Information prUCedures wio exposure [15 incidents]. All addressed by retraining of staff. dtiti'2014 Program DVD Deionized water equipment technician entered into laboratory I??i'612 Ftestricted access issues [4 incidents] Unannounced improper Haynes PP Information unannounced visitor Program A robotic plate stacker holding virus titration plates tPoliovirus Sabin 1.755130 Spills Inside ESL: [1 incidenl] rah-o: plate flop-ed over Haynes PP vaccuie strain: rio1 wild-type] tipped over and embed s1oo a'Izl sol led: ecu p'rie'?. suspension-virus. Spill was clea nod and decontaminated according to rep-a rec protocol. Equipment was repaired. 591212014 Program NCIRDF Freezer operating in LEH corridor - violating corridor policy 15; T421 Incorrect implementation of established satetv Iriccrroc?. plecemeri?. o? Havnes GHV Information procedures wi'o exposure [15 incidents] All addressed etiurp-i?e-it bv retraining of staff. January 2012 - Program DEID Pass through autoclave in our area has been inoperable several Equipment, BEG, autoclave failures [15 incidents. all I'qu pmert acacia-is! out Kuehl RD present Information times resulting in our staff being unable to autoclave infectious waste in a by requesting re pairs] o? se'v ce 1. January 2b12 - Program DBD Walk-in relrig eraior and freezer rnalfunctioned several times. Entire 13ft sass Equipment. BSC. autoclave failures [15 incidents. all Egu piner-t - two l'i-I'l Kuettl present Information centents of both Units had to be transferred to alternate storage area by requesting re pairs] until repaired. This temporarilyr put contents of those units outside secured area. aft-2013 Program DBD Boxes were stored underneath the chemical shower blocking full access. Incorrect implementation of established safety Imp-rope std-age Kuehl Information procedures exposure [15 incidents]. All addressed by retraining of stall. #2432014 Program NCIFIDF DBD HVAC system was not recovering all HEPA filtered exhaust from thimlole 133423. 424A-C airflow issues [1 1 incidents. all addressed by "ol recoveri'ig Kuetil MVPD Information of 8505 in Labs requesting repairs by F5 personnel] fi 'eree from F5839 3152013 Program DBD FS contractor entered EELS laboratory without permission or notification. le424A-C Restricted access issues [4 incidents] Unan ncunced improper Kuehl MVPD Information Subsequently. lab restricted cardliev access to only those working in the visitor suite. 6-?16-?2014 Program The EEG failed certi?cation because of leaking filters. 13-3430 Equipment. BEG. autoclave failures [15 incidents. all BBC ?aileo certi? cation Haynes Information bv reguesting re pairs] ile Bl?tll?E] ti terst DFt?i FT - Not for distribution may contain sensitive invormation or factual errors. Program Lab Incidents All Fteported Incidents 4 Program DVD ageing EISC [#55355] failed certification because of a defective sash. 135-432 Equipment, BBC. autoclave failures [15 incide rits. all EEG "ailen corti? cation Haynes MM Information by requesting repairs] [leakirg fi ters] Recurring Program NCIHD Some shelves that held infectious waste to be autoclaved are too high 13-"5434 J?tny other safety concern reported by lab personnel [3 Sea-2e cesgi'i issue Haynes MMHH Information for many individuals and pose a potential haPard since one has to hold incidentsi the containers over their heads to place them on the shelves or load them in the autoclave. trir'EDIn Program DVD BSD was not opened completely The sash bounced back and hit the 1856-4053 Physical injuries in lab areas {9 incidents] REC sas" bounced oact Haynes MMRH Information la boratorian in the head. 351412013 Program DVD autoclave - steam outage tore-tn Equipment. 350. autoclave failures [15 incidents. all Fnu pmert steam outage Haynes liiz?Fi?i-i Information by requesting re pairs] 8-21-9013 Program DVD autoclave malfuntion tar? Equipment, BBC. autoclave failures [15 incidents. all I:th pmert Auroc ave Haynes Information by requesting repairs] mal?sncticn JUli-f 5" DVD Staff cut hand with scalpel while opening Rotaelone EIA vial the 1337-4219 Portutaneous Injuryf potential paranteral Cut from scalpel Haynes GRV Infurmamn live agent}. Reported to DHC. Implemented use of scissors rather inoculation [5 incidents] than scalgels to prevent future incidents. 1-?2013 Program Staff memberfelt dizzy and light headed. reported to 13:? 148 Any other safety concern reported by lab personnel [3 that no: fool ng wet Haynes (.5141.-r Information incidents: af21J2013 Program DVD An alcohol thermometer was dropped and broken. nothing splashed on LER Spills outside a BBC [10 incidents] broken thermometer: no Haynes Information personnel. The sharps and spilled alcohol were cleaned up using the exposuer cleaned up Chemical Spill Cabinet. Program DVD Disinfectant {ny Sept 333] leaked from original containers. Safety help WIT-428 Spills outside a BEE: [1 incidents] Disinfectant leaked: clear Haynes GFIV Information desk ticI-tet generated for help With clean up. up 11:2??2013 Program DVD Over-exposure to bleach fumes while decontaminaling walk?in for repair. Spills outside a BBC [1 incidents] Chorrical inhalation Haynes Information [bleach] ariraot 4 Program DVD Chemical spill in shared space by Team. The spill was ti'r'LEFt Spills outside a BBC [1 El incidents] Ctierr'ical seill: cleared up: Haynes PP Information cleaned up by Ftabies Team. but our lab staff were not notified of the communicator la as incident. Improvements were made in communication between labs. iri'proved April and June Program DVD While vortet-cing stool suspensions [potentially containing Poliovirus? ?fe-066 Spills outside a BSC [10 incidents] vortea?. rig causes test tube Hayneg PP 2D14 Information Sabin vaccine strain. not wild-type]. the test tube caps Imore shaken oIt caps to come all: stool and stool suspension spilled Area was decontaminated according to spilled. decontaimiration protocol. clean uo Program DVD Fitter business hours. a freezer alarmed and FSE called the wrong tBr'?r LER Poworoutages. emergency response issues [5 [hp armed sewer outage Haynes MMRH Information personnel to come in and empty the freezer. incidents] NIH Program NCIRDF DVD Gloves found Il'l regular trash. 1517-212 Incorrect implementation of established sater disposal of oves Haynes Information procedures wi'o exposure [15 incidents] All addressed by retraining of staff. NIA Program DVD LInshoathed sharp found on counter top. thT-212 Incorrect implementation of established safety Incorrect storage Haynes Information procedures We exposure [15 incidents]. All addressed by retraining of staff. Program DVD Acid cabinet was missing secondary container to contain potential spills 1&rT-212 Incorrect implementation of established safety t.-1ssirg Haynes GFIV Information procedures exposure [15 incidents]. All addressed by retraining of stall. MIA Program DVD BSL3 autoclave failure: delayed waste disposal. tat-"1424 Equipment, BSC. autoclave failures [15 incide me. all Equ pinei-t? Autoc ave Haynes GRV Information by reguesting re pairs] Program DVD Items blocking the eyewash station 1&rT-424 Incorrect implementation of established safety Incorrect std-age Haynes GFIV Information procedures exposure [15 incidents]. All addressed by retraining of stall. Program DVD Mercury found in lab tart-431 Incorrect implementation of established safety Incorrect Haynes GRV Information procedures exposure [15 incidents]. All addressed marer a ?ourd by retraining of stall. Program NCIRDF DVD 2-mercaptoethanol opened outside of chemical tume hood. 1317-505 Incorrect implementation of established satety use o1 material Haynes Information procedures we exposure [15 incidents] All addressed outside fume lice-c by retraining of staff. 1-29-9013 Program DVD Fridge - failure to maintain temperature Equipment. BEG. autoclave failures [15 incidents. all I'gu pmert Fridte Haynes GFIV Information by requesting re pairs] MIA Program DVD Temporary loss of negative air pressure in all labs tBr'i'th airtlov.I issues [1 1 incidents. all addressed by it r" any Haynes GFIV Information reguesting repairs by F5 personnel] Program DVD BSL autoclave - display indicated a door interloclo' process failure [red IBr'Tth Equipment, BSC. autoclave failures [15 incidents. all Equ pinei-t - Autoclave Haynes GRV Information ?ght]. by requesting re pairs] arid-"2013 Program DBD Sampler Substance Iran sport in passenger elevators instead of freight 1ar'all Incorrect implementation of established safety Imprope- Ira-report Kuehl FID Information elevators procedures exposure [15 incidents]. All addressed by retraining of stall. 2-?15-?201 3 Program NCIFIDF DBD Electronic air pressure device turned off HVACI airflow issues [1 1 incidents. all addressed by A pressure device off Kuetil MVPD Information requesting repairs by F5 personnel] NIA Program DBD Autoclave failure. BSL3 mama-1 Ecuipmem. BSC. autoclave failures [15 incidents. all Fqu pinert - Kuehl MVPD Information by requesting re pairs] Ia I..re: re be red arts-"2014 Program DEID EISLS procedure room had a door with fixed hinges leading to leakage of tam-"424C. Hypo: airflow issues [11 incidents, all addressed by DS. rlanr leao 'c lea-raga of Kuehl MVPD Information air into common corridor. No live organism work was in progress. requesting repairs by F3 personnel] a corr doi': I'o Ive organisms ans-amt Program DBD Air flow reversed roams airflow issues tit incidents. at addressed by A r" ov- Kuehl MVPD Information requesting regairs by F5 personnel] 9 33352015 new FT - Not for distribution may contain sensitive invormation or factual errors. Program Lab Incidents All Reported Incidents [b38141 U.S.C. State Statute 4M2 Bore silicate glass tube of S. pneumoniae cell suspensron tlml. Program DED tSfB-212 Spills outside a BSC [1 El incidents] Tub-e glass broke New s'.af1 Kuehl RD cracked when new staff spun it in conical holder. No injury. 0" cemliluge Decontaminatioi?t procedures were correctly followed. New staff was [It [3}:42 5 26 am} retrained in proper centrifuge golicy. Program ID Centrifuge com?actor out himself while working on centrifuge in Physical injuries in lab areas {El incidents] Cur "rom El'tltip't?E'tt Information no Infectious agents present. .. 252mm [3:13:42 252mm 2i'1r'201 :1 Program DBD Latex gloves were too no in regular trash. It was determined Goodwill 1S-?0ffioe area Incorrect implementation of established safety Incorrect disposal of ov as Kuehl Information staff were using gloves during cleaning and disposing of them procedures exposure [15 incidents]. All addressed improperly. by retraining of stall Na". PROGRAM DPEI Potential reduced airflow intol - I Irflow reducedl I r't ow Inform-laian ?1:13:42 ?3:133:42 US [bil3ti-5l'2-Uslsug- 2523i?; [t :[31242 5-?7?f2t113- Program ID While using a ferret necropsy tool, thumb was stressed and became 131653914 Ergonomic injuries [5 incidents, all reported to Th..mb stress .J Stevens Information swollen. Ivlodilied the procedure to prevent further injury. from tool ID Frnger was cut by glass ampule containrng non-infectrous Percutaneous Injuryf potential parenteral Cut from glass Stevens VSD reagents. Inactivated vaccine virus work was performed prior to inoculation t5 incidents] cut; reported to OHC. Implemented transfer of similar reagents to plastic containers before entering BS L3 labs to prevent future lniuries. Program ID attenuated HTNQ candidate vacclne virus was grown in BSL2 115130 Use of inadequate safety level [2 Incidents] grawr In BSLE SSE Stevens IP Information Else on two occasions; no N95 respirator used. AdditIOnal training on twice: Ira no prov tled standard and practices was provided to prevent future incidents. 12ft 2mm 3 Program ID Egg dropped on floor. The ongoing experiment with the eggs attempted (bji3ji42 Spills outside a it El incidents] Egg dropped: no viruse Information ecovery of I I present In egg: soill was (bum-42 lowing-IBE'app'fEiv'ei? protocols. However. the experiment was not 2626]th decorltalnir't-Ited (bj?3ji42 262301] successful and no virus was present in eggs. Spill was decontaminated 262 am) following protocol. also-em 4 Program ID 10% formalin leaked onto hands and clothing: reported to OHS. All team 1?.?5124 Spills outside a it El incidents] Ioinalir- witt- Stevens VSD Information members were instructed to use only designated. leak-proof containers hands-clothing: staff for sample transport to prevent future incidents. instructed to use leak-proof conta ners elite-"2014 Program ID Loss of airflow 23 anCi' airflow issues t11 incidents. at addressed by A r" so Stevens 5qu Information requesting repairs by F3 personnel] Program ID Airflow reversal Hvac; airflow issues [1 1 incidents. all addressed by I'l r" aw Stevens Information requesting repairs by F8 personnel] PROGRAM DFWED July 2013. There was a lightning strike which caused an electrical surge and 9th Lightning strike caused changes in air flow l?liners Hill. Peter ED LE and information and building wide-airflow problems Changes in air flow and made it floor lab corridors Gern er Smiclt WDPB labs nearly impossible to open the lab hallway doors over aprottimately 1 In 23 hour There was a lack in communication that folks should not be in the lab working with the negative airflow not working. Emails came at least 30 to 45 minutes later that said not to work in the labs For future incidents. the Pa system will be used to inform the labs. NIA PROGRAM NCEZID: DFWED The phone system in Eturlding 2'3 is "voice over internet". When the 23:7th and telephone system service lost: no other communication Izcu p'ne". ssue Vince Hill. Peter EDLEI and information internal or is dowrt. laboratories lose phone as well as computer service. floor lab corrldors ntect'ranisrns In labs for possible events that would sysle'r'i Gerrier Srnidt WDPB labs Staff in labs could not use building phones to communicate. No backup require immediate comms in 23 corrirnunicatlon plan was In place. The problerrt was brought to the attention of the Infectious Diseases Safety Committee. Continued phone outages have occured periodically Tltis Is an ongoing safety concern because communications from the labs to the outside are stopped and no communication would be possible In the event of art accident. Program NCIRDI DBD No airflow in lab corridors. Air handlers and exhaust fans shutdown anc; airflow issues 1 incidents. all addressed by r" ow Kuehl MVPD Information simultaneously. No live organism work was in progress. requesting repairs by FS personnel] Program DBD Finger was injured after getting stuck in door jarnb {corridor eriterior Physical in uries In lab areas {El incidents] Elco' an ricer I'Ijuryj- Kueltl MVPD Information door]. Filled out incident report form. notified safety cemmittee. Program NGIRDHD Unplanned power outage in sequencing facility 23a? Power outages. emergency response issues [5 mo a-Ined oerE' outage Stevens 5qu Information incidents] 1.8092014 Program Power outage in sequencing facility 23-"all Power outages. emergency response issues [5 mned onwe' outage Stevens Squ Information Incidents] Program NCIRDIID Unplanned power outage in sequencing facility 23lall Power outages. emergency response issues [5 L. 1p a'Ined aowo' outage Stevens Squ Information incidentSI Program DBD Goodwill worker in unauthorized location all labs Restricted access issues [4 incidents] UrIarIrIourIced Kuehl MVPD Information visitor aims-"2014 PROGRAM a DPDM contractor was washing gels that contained a metal strainer. 323- 9-440 Cut Program Submitted information and a small piece of metal that was protruding from it cut her finger. The contractor sought treatment at the CDC clinic. GIL-2014- Program l.l't'ater puddles forming around freezers. slippery floors many l'tny other safety concern reported by lab personnel [3 'v?rl'ate' on ocr Haynes many Information incidents] 10 33352015 DFif-i FT - Not far distribution may ccmain sensitive invurrna1iun or factual errors. I 42 .S . C. Program Incidents 2 Potential inhalation of infectious aerosols? {1 Ira-spasm? incident} Program rucmmr DVD, In, DBD Potential exposu'i'?'ib Infurma?on inCidenL (blisizaiz'iusc. 262a{h) in care facilities during thEI multiple {bii3li42 262a{h) 1 1 3.352015