ARTICLE IN PRESS

American Journal of Infection Control ■■ (2016) ■■-■■

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American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Brief Report

Biological accidents at work among resident physicians in specialist

training at Bari University Hospital, Italy
Antonella Basso MD, PhD a,b, Rosaria Serra MD a, Ignazio Drago PhD b,
Leonardo Soleo MD a,b, Piero Lovreglio MD, PhD a,b,*
a
Residency School in Occupational Medicine, University of Bari Aldo Moro, Bari, Italy
b
Interdisciplinary Department of Medicine, Section of Occupational Medicine “E.C. Vigliani”, University of Bari Aldo Moro, Bari, Italy

Key Words: The phenomenon of accidents at work was investigated among the resident physicians of the School of
Underreporting Medicine, Bari University, by a self-administered anonymous questionnaire probing personal details and
Accident registry inquiring about any accidents at work experienced during the training period, and by a comparison with
Surgical area
the accidents reported to the Hospital Accidents Registry. At least 1 biological accident was reported by
18.2% of the 450 participants, this percentage being significantly higher in the surgical area (33.3%), where
biological accidents were much more rarely reported to either the Residency School Director or the Ac-
cidents Registry. In conclusion, despite an overall reduction compared with the past, the frequency both
of biological accidents and of underreporting is still high among resident physicians, particularly in the
surgical area.
© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

INTRODUCTION ance with the Ministry of Education, Universities, and Research

Biological accidents at work are the most frequent type of ac-
cidents experienced by health care workers. 1 Although the
phenomenon has been extensively investigated among physicians
and nurses, studies among resident physicians in specialist train-
ing are few and often limited to specific years of the training course
or to a single type of residency school, in particular the surgical
area.2,3 The aim of the present study was to perform an overall anal-
ysis of accidents at work among resident physicians at Bari University
Hospital, Italy, considering all the specialist areas and all course years.
MATERIALS AND METHODS
The study recruited 615 resident physicians at Bari University
School of Medicine, attending 34 residency schools, subdivided into
medical, surgical, and other clinical-diagnostic areas in compli-
* Address correspondence to: Piero Lovreglio, MD, PhD, Dipartimento
Interdisciplinare di Medicina, Sezione di Medicina del Lavoro “E.C. Vigliani”, University
of Bari, Piazza Giulio Cesare, 11, 70124 Bari, Italy.
E-mail address: piero.lovreglio@uniba.it (P. Lovreglio).
The preliminary findings of this study were presented as an oral presentation
at the 31st ICOH International Congress on Occupational Health, Seoul, South Korea,
June 2015.
Conflicts of interest: None to report.
Decree.4 As entry criteria, the schools had to have obtained grants
for specialist training for the 4 consecutive academic years (AYs)
from 2008/2009–2011/2012 and the resident physicians had to have
followed through all the training activities at Bari University Hos-
pital, site of the School of Medicine, and of the administrative
registration of accidents at work for the Accidents Registry. Twelve
residency schools and 250 resident physicians did not fit these cri-
teria and were not considered in the study.
At the end of AY 2011/2012, all the recruited resident physi-
cians were asked to complete the self-administered anonymous
questionnaire and to sign the informed consent form. The
semistructured questionnaire, previously validated in a sample of
resident physicians in each of the 3 areas, inquired about personal
details and about any accidents at work that the participant had ex-
perienced during each course year.
To compare the number and characteristics of the accidents re-
ported in the questionnaire with the data in the relative Accidents
Registry for the same study AY, information in anonymous form
about recorded accidents for all the enrolled resident physicians was
obtained from the General Direction of Bari University Hospital.
Statistical analyses were done with SPSS (version 14.0, SPSS Inc,
Chicago, IL). The incidence rates were calculated as the proportion
of resident physicians who experienced a biological accident during
the specific reference period of 1 year.2 For the categorical vari-
ables, statistical comparison was made using the χ2 test, and for the

0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2016.06.015
 ARTICLE IN PRESS
2 A. Basso et al. / American Journal of Infection Control ■■ (2016) ■■-■■

Table 1 Table 2
Distribution of the resident physicians by area, sex, and course year Incidence per person-year of biological accidents among resident physicians by area
and course year when it occurred
Participating resident physicians
Year
Course year (n)†
Area* 1‡ 2† 3‡ 4‡ Total†
Area Sex* n 1 2 3 4
Medical 0.05 0.02 0.04 0.02 0.04
Medical (39.3%) Man 53 15 10 16 12 Surgical 0.23 0.19 0.25 0.20 0.21
Woman 124 32 30 28 34 Other clinical-diagnostic 0.11 0.05 0.07 0.02 0.07
Total 177 47 40 44 46 Total 0.12 0.08 0.11 0.09 0.10
Surgical (28.7%) Man 44 6 9 10 19
Woman 85 21 18 14 32 *Comparison by course year for each area and total: Not significant.
†P < .01 for surgical area versus other clinical-diagnostic area versus medical area.
Total 129 27 27 24 51
Other clinical-diagnostic Man 35 8 11 7 9
‡
P ≤ .001 for surgical area versus other clinical-diagnostic area versus medical area.
(32.0%) Woman 109 27 23 26 33
Total 144 35 34 33 42
Total (100%) Man 132 29 30 33 40
Woman 318 80 71 68 99 accident to the Accidents Registry. In the medical area, 68.7% re-
Total 450 109 101 101 139 ported to the former and 50.0% to the latter, and in the other clinical-
*Men versus women: By medical area, surgical area, and other clinical-diagnostic diagnostic areas, reporting to the Residency School Director and
area: P < .001. Accidents Registry was 77.8% and 63.0%, respectively. Moreover, fewer
†
Distribution by course year: Surgical area P = .002; medical and other clinical- resident physicians in the surgical area than in the other 2 areas
diagnostic areas: not significant; and total P = .034. had recourse to the Emergency Department (42.7%), and viral
markers monitoring was not performed for 62.7% of victims.
continuous variables, parametric tests were performed after check- Postexposure prophylaxis (PEP) was taken by 31.3% of victims in the
ing for a normal distribution by Kolmogorov-Smirnov test. medical area, 18.3% in the other clinical-diagnostic area, and only
Dependencies among variables were verified by logistic regres- 8.0% of those in the surgical area. Overall, PEP was done in 1 case
sion models. The level of significance was set at P < .05. against HIV, in 4 cases against hepatitis B virus, and in 3 cases against
hepatitis B virus and HIV. For half of the PEP reported, the resi-
RESULTS dent physicians did not report which viral agent had been targeted.
Logistic regression analysis confirmed that in the medical and
The questionnaire was completed by 450 resident physicians, the other clinical-diagnostic areas, taken together, the area influ-
73.2% of those recruited (Table 1). In total, 130 accidents at work enced the frequency of reporting to the Residency School Director
were reported in the questionnaires, 118 biological (17 by splash) (odds ratio, 8.71; 95% confidence interval, 2.53-21.51; P < .001) and
and 12 nonbiological. By contrast, in the Accidents Registry for the presenting to the Emergency Department (odds ratio, 6.91; 95% con-
same AY, 80 accidents had been recorded, 69 biological (9 by splash) fidence interval, 2.73-17.52; P < .001), whereas neither sex nor course
and 11 nonbiological. Nonbiological accidents occurred largely as year had a significant influence on the dependent variables.
a result of falls, whereas there was 1 road accident and 1 accident
while moving a patient. In view of the different significance of bi- DISCUSSION
ological versus nonbiological accidents in terms of risk factors, the
latter were not considered further. The present retrospective survey showed that a total of 18.2%
The percentage of biological accidents was higher among resi- of resident physicians reported experiencing at least 1 biological
dent physicians in the surgical area both in the questionnaires (63.6% accident in the questionnaire. This frequency is much lower than
vs 13.5% medical vs 22.9% other clinical-diagnostic areas) and in the the percentage observed in the past among medical residents and
Accidents Registry (43.5% vs 21.7% medical vs 34.8% other clinical- students, in line with the overall reduction in recent years of bio-
diagnostic areas), showing a difference at the limits of significance logical accidents observed in other health care worker categories.5,6
between the data from the questionnaires and the Accidents Reg- In agreement with studies in the literature, surgical resident phy-
istry only in the surgical area (P = .05). sicians are most at risk of biological accidents, in terms of both
At least 1 biological accident was reported by 18.2% of resident frequency (33.3%) and incidence (0.21 per person-year). Even when
physicians, with significantly higher levels in the surgical area (33.3%) analyzing the surgical area alone, the incidence we observed was
than in the other clinical-diagnostic (16.0%) and medical areas (9.0%) much lower than values reported in the past.5-8
(P < .001). Only in the surgical area the percentage of resident phy- Previous studies have reported a greater frequency of biologi-
sicians who referred at least 1 biological accident was higher for cal accidents at the beginning of the training period, and it has been
men (42.2%) than for women (28.2%). hypothesized that lesser experience is a risk factor that can be
The incidence of accidents per person-year was virtually over- reduced or eliminated through adequate training before starting the
lapping for each of the different course years, both subdivided by residency course.2,6,9 Instead, in our study the incidence of biolog-
area and when considering the whole sample (Table 2). When the ical accidents per person-year did not seem to be affected by the
resident physicians from each area were further subdivided by sex, course year. By contrast, in the surgical area, sex seems to be a more
no difference was found in the medical and other clinical-diagnostic important factor. Probably in this area the trend for biological ac-
areas, whereas in the surgical area accidents tended to reduce pro- cidents depends on organizational aspects and it cannot be excluded
gressively from the first to the fourth year in men (P = .004), whereas that this may include involving women in operating room activi-
in women they tended to increase from the first to the third year, ties later than men.
and were highest in the third and fourth years. The difference Underreporting of biological accidents is a common phenome-
between men and women was significant (P ≤ .001) only for the first non among all health care workers, making it particularly difficult
year. to study the incidence and circumstances of such injuries.3,10,11 Lack
The actions taken by resident physicians after the accident are of time is the first cause of failure to report an accident that was
listed in Table 3. In the surgical area, only 26.7% reported the ac- reported by resident physicians.8,9 Moreover, the phenomenon may
cident to the Residency School Director and 18.7% reported the be aggravated by their dependent role, which may cause them not
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A. Basso et al. / American Journal of Infection Control ■■ (2016) ■■-■■ 3

Table 3
Percentage of biological accidents reported in the questionnaires for which actions were taken, by area

Medical area Surgical area Other clinical-diagnostic area

Action taken after the biological accident (n = 16) (n = 75) (n = 27)
Report to director of residency school Yes 68.7* 26.7* 77.8*
No 18.8 65.3 22.2
Not known 12.5 8.0 0.0
Report to accidents registry Yes 50.0 18.7* 63.0*
No 18.8 65.3 22.2
Not known 31.3 16.0 14.8
Presentation to emergency Yes 81.3* 42.7 85.2*
No 18.7 57.3 14.8
Viral markers monitoring Positive — — —
Negative 81.3* 36.0* 59.3*
In course — 1.3 3.7
Not done 18.7 62.7 37.0
Postexposure prophylaxis Yes 31.3† 8.0* 18.5*
No 68.7 92.0 81.5

*P ≤ .001.
†
P < .05.

to report accidents for fear of being stigmatized or losing other op-
portunities. Further factors that may accentuate underreporting in
this workers category are a poor perception of the risk and of the
need for PEP.3,11 In our study, underreporting seemed mainly to affect
the surgical area, as shown by the data obtained from both the ques-
tionnaires and the Accidents Registry and by the logistic regression
analysis.
Similar reasons could lead to a tendency not to report an acci-
dent at work in questionnaires, even if they are anonymous. This
must surely be counted among the limits of this survey. A possi-
ble recall bias must also be taken into account, because resident
physicians might have had less difficulty in reporting accidents that
occurred during the course year when the survey was conducted
and they completed the questionnaire, compared with those that
occurred 3 or 4 years before. This would also mean that the
underreporting phenomenon was underestimated.
CONCLUSIONS
Our study is among the most complete surveys of the phenom-
enon of biological accidents occurring among resident physicians
to be conducted in past years. Our results show an overall reduc-
tion of biological accidents compared with previous studies,
confirming the efficacy of the procedures and devices adopted to
combat the phenomenon. Nevertheless, the frequency still seems
high, in particular in the surgical area. Indeed, the percentage of sur-
gical residents who underwent viral markers monitoring after a
biological accident seems particularly low, and this illustrates the
urgent need to institute adequate intensive education campaigns.
In addition, the surgical area seems to be particularly hard hit by
the problem of underreporting, and this confirms the limited utility
of the information present in the Accidents Registry.
Acknowledgments
The authors thank the General Director of Bari University Hos-
pital for the collaboration provided.
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