Lost your finger!!! How could it have been prevented?

My topic today is based on a real event.

Ok so the finger wasn’t completely lost, and I exaggerated that somewhat, but it was deeply sliced and resulted in stitches along with two weeks off work.

The location

A laboratory. Somewhere many of our customers work.

The story

Use of a wire cutter, for cutting metal.

An old piece of lab kit. All labs have old bits of kit kicking around that are there for seemingly simple jobs, right?

And they use them every day with no problems.

Until one day, something like this happens.

It could have been anyone.

Why did it happen?

There are many investigation techniques and forms of root cause analysis that professionals use to determine how accidents occured.

For the standard Manager or employee trying to solve the mystery; you just need to keep asking why.

Why did their finger get cut?

Because they were changing a consumable part on the machine that meant replacing the wire. The wire was stuck so they pulled at it resulting in the slice.

Why was it stuck?

Because it turned out the screw that should work seamlessly was quite loose from the frequency of use, and there was no form of safety check, service or maintenance.

Why was there no service or maintenance?

This is quite often the case for smaller benchtop simple bits of kit. Maintenance is quite often done on an as needed basis, by the equipment operators.

Why was there no pre use checklist?

Neither the manual, training given or risk assessment suggested as such.

Why did they not suggest as such?

The manual was actually the incorrect manual for the kit. The kit was acquired in the 90’s before much legislation was around, and the manuals that were available made no reference to safety information of any kind.

The manufacturer training demonstrated use as they were using it. Which even included touching the wire with bare hands.

The risk assessment was written by the operator (the person who had injured themselves).

Why did the operator write the risk assessment?

There’s a good question. Firstly, let’s celebrate that they did. Because I’ve seen many an operator not do so.

They key here is that the operator is not trained in risk assessment.

No consideration was given to current safety standards, and available safety equipment such as gloves. A simple measure that would have removed direct contact entirely.

As organisations, there is a responsibility to review risk assessments based on the change of use too.

Over the years this piece of equipment had been in higher demand, resulting in quicker wear and having to change the wire 3-4 times a week.

This increases the risk of injury, and it is the organisations liability to make sure that is considered.

So where do we get to?

We can’t dictate that the equipment should be replaced, because that comes with a cost. Although there is likely to be automated, much more efficient versions of these wire cutters now, they are also likely to cost tens of thousands.

But what we can do is look at how it is used. Look at what is available to make the wire changing easier, less frequent, and introducing safety training to staff. So that they can identify things like how risks might change over time.

So have a look at your small equipment. Because chances are, there are higher risks with those smaller, older, plug and play type systems, than there are with your HPLC.

This case was fortunate that no nerve endings were affected, but this could have resulted in the permanent loss of feeling, or worse.