Excerpts from BDM reports
A stack of 161 Biological Defense Mishap reports provided to The Frederick News-Post under the Freedom Of Information Act included a range of incidents from jammed fingers to needlesticks, which employees report to the safety office and medical division at the U.S. Army Medical Research Institute of Infectious Diseases.
The mishap reports were filed at USAMRIID between April 1, 2002 and Dec. 1, 2005.
Excerpts from the mishap reports are below. The U.S. Army Medical Research and Materiel Command, which oversees USAMRIID, redacted names and other identifying information.
Date redacted - After assisting a veterinarian with returning a monkey to a cage, a female employee was scratched on the neck. The Safety Office's conclusion was, "Working with (nonhuman primates) is unpredictable. Employee had limited time working with (them) and no formal training. Employee to be enrolled in (nonhuman primate) class."
Date redacted - A rhesus monkey bit an employee on the middle finger while the employee was trying to clean out the animal's cage. The employee reached into the cage without restraining the monkey, according to the conclusion.
The supervisor wrote that he or she would be looking into devices to remove debris from cages.
Date redacted - A surgeon noticed blood in his or her glove after surgery on a monkey. The blood might have been the result of a needle stick.
First aid was performed after the surgery and the officer was cautioned to be extremely attentive during surgery.
2:45 p.m. - A slurry of acetone and dry ice in an evaporation unit bubbled over and spilled after an employee added more dry ice to cool the unit. The supervisor stressed the use of special gloves and replaced the coolant with a water cooling system.
4 p.m. - An employee slipped and fell in a shower while leaving (after showering) the "hot side" of a locker room shower. The supervisor wrote the shower may have inadequate safeguards and was looking into shower mats.
7:30 a.m. - An employee was placed on antibiotics after effluent leaked from a pipe in the ceiling of building 1412. The liquid may have come from "hot suites/monkeys."
12:15 p.m. - An employee caught a finger in a door jamb. The accident was probably caused by the person being in a rush to accomplish an excessive daily workload, according to the report.
7:20 a.m. - An employee was bitten on the left thumb near the fingernail by a plague-infected monkey while attempting to secure the monkey to an armchair. The employee returned to work at 11 a.m., according to the report.
A second report, which also has a monkey biting an employee at 7:20 a.m. while attempting to secure the monkey to a chair, states the employee returned to work at 7:30 a.m. and does not mention anything about the plague.
The employee was counseled on the proper way to handle and restrain conscious monkeys.
9:45 a.m. - An employee was bitten by a monkey while positioning the animal. The supervisor counseled the employee on safe working procedures.
"Accidents do/will happen," the report states.
10 a.m. - An employee stabbed his or her thumb with a needle after injecting a goat with the same needle. The supervisor discussed proper handling of sharp objects with the employee.
4:15 p.m. - An employee punctured his index finger with a suture needle while performing surgery on the abdominal cavity of a nonhuman primate. The surgeon was wearing double gloves, which reduced his dexterity.
"Haste may have played a part in this," the report states.
9:30 a.m. - An employee was bitten by a black mouse that had been inoculated with a virus redacted in the report, saying "no live virus."
"Inadequate safeguards. Always a risk with living animals," the report states.
2 p.m. - An employee mistakenly placed non-infectious cells in an incubator containing SARS cultures. Without wearing a mask, he opened a clean incubator that housed SARS cultures.
"The specific cause was lack of communication," the report states. "...the incubator did not have a sign indicating 'SARS cultures inside.'"
10 a.m. - A surgeon received a puncture wound while using a suture needle, causing "significant exposure."
The supervisor reviewed the proper method for handling suture needles with the employee.
3 p.m. - An employee tried to move a toy in a monkey's cage when the monkey grabbed his face shield and mask, scratching his face.
"In the future, this individual should request additional assistance for difficult...monkeys," the report states.
9:30 a.m. - An employee who works with SARS may have gotten an upper respiratory infection due to the sharing of masks with other employees. According to the document, the employee agreed to wear the mask assigned to him and label it properly.
9:05 a.m. - A technician was scratched on the hand by a monkey that had been infected with an agent that was redacted in the report. The technician was not wearing protective Kevlar gloves at the time. The report states the supervisor, who was present during the procedure, was at fault for not requiring the technician to wear proper protective gear.
4:30 p.m. - A backed-up drain caused water that may have been contaminated with plague to overflow. The exposure to employees was limited to their shoes.
9 a.m. - Employees emptied unsterilized trash that may have contained Burkholderia mallei, a bacteria that causes glanders. The employee who might have been exposed was given an antibiotic.
(According to the Web site for the Centers for Disease Control, glanders infections are usually fatal within 7-10 days.)
9 a.m. - An employee walked into a "hot side" room with glanders of building 1412. The reports states defective tape should be replaced and indicator strips should be improved.
3:35 p.m. - An employee walked into a room that contained two animals that may have had monkeypox. The employee had failed to look at the sign before entering.
9:30 a.m. - An employee entered a hallway without using proper protective respiration.
The accident was caused by "Lack of skill or knowledge...only the third time had ever entered a containment suite...attitude: inattentive," the report said.
DATE REDACTED - An employee may have been exposed to SARS virus when he was in a room in which trays that had not been treated according to standard protocol were being processed.
According to the report, the trays were inadequately decontaminated. One of the researchers had eliminated a step in the decontamination process. According to the report, that person was removed from the lab.
3:45 p.m.- An employee entered a room two hours after a monkey had been infected with an aerosolized agent.
"Incorrect sign on door, unclear information on exposed animals, change in procedure from earlier in same day," were the causes, according to the report.
2:15 p.m. - Rabbits that had been exposed to an aerosol version of tuberculosis briefly managed to bare their snouts to employees. The employees were unmasked, but three feet away and received negligible exposure, the report states.
8:45 a.m. - A surgeon cut his finger while amputating the finger of a monkey with herpes B. The accident was blamed on inattention to sharps during the procedure.
6:30 p.m. - Employees discovered a shower door that led to a "hot" suite had been propped open.
"It is in my opinion we could have been potentially exposed to some agent," the employee wrote.
11:01 a.m. - An employee was scratched on the hand while trying to perform a physical examination on a rhesus monkey.
"Soldier agrees cut/scratch resistant gloves could have prevented this mishap," the report states.
2:15 p.m. - An employee stuck his finger with a needle while performing a procedure on an anesthetized mouse that had been infected with anthrax. The mouse gasped and twitched its body, causing the employee to stick his finger, according to the report.
9 a.m. - While transporting two flasks with anthrax in them, an employee noticed hardened liquid streaks on the outside of the flasks. The report concluded that researchers should wear respirators at certain times when working with flasks.
"This is a rare occurrence," the report states.
12:30 a.m. - An employee poked his hand with a sharp object when wiping a bio-hazard bag before removing the bag.
"The environmental contributing factor was use of a less-than-ideal sharps disposal method and a potential personal factor was lack of knowledge that pipette tips can cause puncture wounds," the report states.
|
