Risk of exposure of laboratory staff to biological agents due to missing clinical information

Health and Safety Executive - Safety notice

Issue

Workers at diagnostic laboratories are being put at risk of infection because of missing information on specimen request forms.

If specimen request forms do not provide sufficient clinical information, then lab staff cannot identify the appropriate safety measures they need to apply to control exposure and possible infection.

HSE investigations have confirmed several occasions when lab staff have been exposed to pathogens capable of causing severe disease. HSE has also investigated exposure incidents in veterinary laboratories linked to Brucella canis infections in dogs linked to a  rise in the number of animals imported from Eastern Europe.

Outline of the problem

Clinical and veterinary diagnostic laboratories receive specimens for testing. Laboratories sort and process these specimens based on the clinical information provided.

If clinical information is inaccurate, incomplete, or there are delays in providing new clinical information to the laboratory, this can result in specimens being processed under insufficient laboratory containment conditions. For example, specimens considered likely to contain Hazard Group 3 pathogens requiring propagation or culture must be processed within a containment level 3 laboratory.

Information needed to identify risks

Anyone who completes a specimen request form, like clinicians, nurses, GPs or vets, should include all information that can help lab staff assess potential risks.

Relevant information that should be included on a specimen request form includes:

• recent travel history
• consumption of unpasteurised milk or cheese products
• contact with imported animals
• other relevant clinical symptoms or information

Clinical information on multiple samples from a single patient

Diagnostic laboratories often receive multiple samples from a single patient over a prolonged period. Different samples from the same patient often lack relevant clinical information.

HSE is aware of cases when the absence of an effective communication system to identify multiple samples from the same patient as high risk has resulted in samples being inappropriately handled in laboratories.

The most common laboratory staff exposures are in relation to the isolation and handling of Hazard Group 3 agents, in particular from blood cultures that were initially processed at Containment Level 2 and later on shown to contain Brucella and Burkholderia species.

Action required

Ensure that specimen request forms contain all relevant clinical information

Duty holders should:

• highlight to clinical staff the importance of capturing clinical details that may increase the likelihood of Hazard Group 3 biological agents being present in patient samples, including:
  • recent history of foreign travel
  • contact with imported animals (in particular dogs from Eastern Europe)
  • association with an outbreak scenario
  • consumption of unpasteurised milk products
• have clear guidelines in place for the completion of specimen request forms
• train clinical staff in the completion of specimen request forms, and consider refresher training

Ensure that laboratory staff act on clinical information provided

Duty holders should:

• train staff to identify key clinical information, and consider refresher training
• have procedures in place for processing samples which may contain Hazard Group 3 agents
• implement a system to link different specimens from the same patient, so that relevant clinical information is associated with all samples from one individual, and appropriate containment steps can be taken in the laboratory

Ensure that record-keeping and IT systems are fit for purpose

Duty holders should ensure that systems can:

• capture relevant clinical details, for example by creating mandatory fields related to travel history or other key clinical information
• allow lab staff to easily view relevant clinical information
• alert lab staff when further information becomes available to clinical staff which could affect laboratory risk assessment or processes

Guidance

• Management and operation of microbiological containment facilities
• The Approved List of biological agents: Advisory Committee on Dangerous Pathogens

Relevant legal documents

• The Health and Safety at Work etc. Act 1974 (on legislation.gov.uk)
• The Management of Health and Safety at Work Regulations 1999 (on legislation.gov.uk)
• The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (on legislation.gov.uk)
• The Control of Substances Hazardous to Health Regulations 2002 (on legislation.gov.uk)