Lab Lesson Learned:

Faulty Autoclave Operation Results in Incident Response and Near-Miss


A Near-Miss is an unplanned event that has potential for more serious consequences. These consequences include injury, property damage, damage to the environment, or business interruption. Recently, Medical Center Operations and EH&S responded to an emergency notification regarding autoclave misuse. A loud whistling sound and a great amount of steam built up in the room providing strong indication of incorrect setup. This incident had the potential to impact personnel and property.

Incident

On October 21, 2012, a Principal Investigator was using a small-door, multi-hinge autoclave to sterilize tools. The door was incorrectly closed, allowing pressure and steam to strongly pass through the gap created in the door.

Root-Cause Analysis

The event described above illustrates the problems created by a failure to follow established procedures. The autoclave involved in this near-miss is the exact one that was used to illustrate correct procedures in the Autoclave Safety Video and Autoclave Safety Procedure; a small, multi-hinged door. This often has the effect of setting off the fire alarm and could seriously injure the user. Some highlights of the video and procedure that directly pertain to the incident are below:

The PI had placed the items in the autoclave, and closed the door. The PI failed to push the right side of the door closed.


A failure to do this results in the pins being misaligned, and introduces a strong potential for injury and fire alarm activation.

When the door is closed properly, the hinges will go directly into the groove located in the frame. The door will be flat against the frame.


After the autoclave is loaded, it is important to wait beyond the purge cycle to ensure that abnormal conditions are not detected, such as the door not being properly seated.

Historical and Potential Impacts

The lack of adherence to autoclave procedures can be costly:
• In April 2010, an incorrect application of the closing and seating procedure resulted in a broken door that had to be replaced.
• In April 2011, a similar failure resulted in pin breakage and door replacement.
In each one of these cases, the door had to be refabricated, taking 6 weeks and costing over $10,000 per door.

Lesson Learned

With any Safety Management System, adequate safety procedures must be developed, understood, and competently applied. Clear, concise and complete procedures have been developed. PIs must neverallow personnel to operate the autoclaves until they have full understanding of these procedures, and sign-off is complete.

If you need explanation about the procedures for using the autoclaves (e.g., liquid cycles, waste cycles), please contact Medical Center Operations at 7-1497. Lastly, if you have any questions regarding safety issues, please contact EH&S at 7-4712.