Occupational Medicine 2003;53:147–150

DOI: 10.1093/occmed/kqg032

CASE REPORT

Investigation of eye splash and needlestick

incidents from an HIV-positive donor on an
intensive care unit using root cause analysis
L. Batty, K. Holland-Elliott and D. Rosenfeld

Background Two doctors working on a busy intensive care unit sustained injuries whilst removing
a chest drain from an HIV-positive patient. One doctor had a needlestick injury into
his finger whilst the other sustained an eyesplash when the chest drain was pulled
out.
Methods Following Department of Health format 'Doing less harm', a root cause and human
factor analysis of the incident was carried out. The aim was to explore the underlying
issues.
Results and Training, cultural and organizational issues were exposed, and are now being
conclusions addressed. This approach has led to a far more effective dialogue with the National
Health Trust concerned than was previously experienced, and there is early evidence
of progress on important aspects of health and safety management at organizational
level. Lack of health and safety training of doctors at undergraduate and post-
graduate level needs to be addressed.
Key words Accident investigation; eye splash; HIV; human factors; intensive care; needlestick;
occupational injury; root cause analysis.
Received 25 June 2002
Revised 3 December 2002
Accepted 7 January 2003

King’s College Hospital Occupational Health and Safety
Department provides services and advice to many
different National Health Service (NHS), public sector
and private sector organizations. In April 2002, it was
alerted to an incident on an intensive care unit (ICU)
in an acute NHS Trust in London. Two doctors were
engaged in removing a chest drain from an HIV-positive
patient during which one doctor received a splash of
pleural fluid to the eye and the other doctor sustained a
needlestick injury to the thumb. Both doctors were seen
at the time in the hospital accident and emergency
department, assessed and treated in accordance with
Department of Health guidelines [1].
In accordance with that hospital’s procedure, the
incident was reported to management on a specific
Department of Occupational Health and Safety, Kings College Hospital,
Denmark Hill, London SE5 9RS, UK.
Correspondence to: Dr L. Batty, Department of Occupational Health and
Safety, Kings College Hospital, Denmark Hill, London SE5 9RS, UK.
e-mail: luciabatty@yahoo.com
‘incident form’ and later to the occupational health and
safety department for follow-up. The incident was
assessed as being notifiable to the Health & Safety
Executive (HSE), and the appropriate form F2508 sent
by the Trust health and safety advisor in accordance
with the Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR) 1995. The head of
nursing for the area had performed an initial investigation
into the facts and identified that the doctor who suffered
the eye splash had not worn eye protection. Upon receiv-
ing the RIDDOR report, the HSE requested a formal
investigation report.
It was decided that a root cause analysis approach to
the accident investigation was appropriate. This format
follows the Department of Health guidance issued in
2001, which encourages a systematic analysis of the
underlying causes of incidents [2]. Further analysis seek-
ing root causes was started using a human factors analysis
[3] (Figure 1) that was later expanded to a causal chain
diagram (Figure 2) in order to gain as full an under-

Occupational Medicine, Vol. 53 No. 2

© Society of Occupational Medicine; all rights reserved 147
148 OCCUPATIONAL MEDICINE
Figure 1. Protective eyewear—human factors.
Figure 2. No eye splash protection—root causes.
standing as possible of the underlying causes of the
incident. It has long been understood that workplace
safety behaviour is the result of different influences within
an organization [3], and so the context of the work, the
doctors’ training arrangements and working practices,
and the culture in that workplace were specifically
examined.
Investigation approach
Appropriate policies regarding health and safety as well as
protection against blood-borne viruses were present at
the Trust level. Written guidance on safety procedures was
also available. The initial report indicated that there was
discretional use of eyewear. It was accepted that constant
use of eyewear for clinicians in intensive care is neither
practicable nor necessary. Protection against exposure to
blood-borne viruses therefore relies on the use of eyewear
in specific circumstances. The decision whether or not to
wear eyewear is delegated to the individual doctor. This
decision would be reliant on the risk perception of the
individual doctor, which in turn would be affected by a
 L. BATTY ET AL.: EYE SPLASH AND NEEDLESTICK INCIDENTS FROM AN HIV-POSITIVE PATIENT 149
number of factors. These factors could include any
training the doctors received, together with workplace
reinforcement by colleagues and supervisors of safe
systems of work. Two perspectives were applied to this
decision-making process by the doctor [4].
First, human factors analysis divides failures into two
groups: (i) error and (ii) deliberate action of the individual
(Figure 1). In this case, it was clear that there was a delib-
erate decision not to use personal protective equipment
(PPE) in the form of eye protection. On further interview,
it became clear that the use of eyewear was routinely
ignored, based on the belief that no significant risk factor
applied. The second method of analysis was to work back
to the underlying causes by laying out diagrammatically
a chain of causes leading to the event. The HSE has
identified that the general safety behaviour of colleagues
and supervisors can be a significant underlying cause of
incidents [5]. The aim of causal chain analysis (Figure 2)
was to identify immediate causes and underlying causes.
The underlying causes can then be subdivided into
general and management causes of failure to use eye
protection.
Analysis of immediate causes
The doctors were interviewed about their health and
safety training. At undergraduate level, they felt that any
advice about splash protection and personal safety
training was obscure and not emphasized. They recalled
being given warnings and advice regarding prevention of
needlesticks and eye splashes by a senior doctor when
they were inducted into the employing Trust. The
personal presentation was recalled, though they did not
refer to written materials that were also provided.
Within a crowded corporate induction programme,
there is reliance upon some safety information delivered
locally. Both doctors had ‘a guided tour’ of the clinical
area, but by a non-clinical staff member, so personal
safety precautions were not discussed. This briefing also
omitted information about local availability of written or
computer-based policies and procedures, such as infec-
tion control. In contrast, nursing colleagues working in
the same area received a longer briefing from their nurse
manager and completed a mandatory induction checklist.
These checklists confirmed that information on manage-
ment responsibilities, location of safety equipment, and
other important clinical and safety information was given.
Interview highlighted that where a medical speciality
team has patients on different wards, there may be no
local unit briefing for those doctors. The doctors referred
to ‘on-the-job training’ as an important method of learn-
ing. They observe procedures before practising. The
doctor who showed them how to remove chest drains had
not worn eye protection. They were asked whether they
had heard of any similar incidents and confirmed that
they had not. Direct local learning from reported safety
incidents of any kind appeared to be uncommon. Sharing
incidents informally was not encouraged and doctors
perceived stigmatization if they did.
The next area of attention was the nature of the
supervision. The junior doctor’s line of supervision for
safety purposes appeared confusing. It was unclear to all
where the doctors were based with regard to the health
and safety management structure, and whether the
doctors involved in the incident were counted in the ICU
safety management returns. The doctor’s appraisals were
carried out by the consultant but concentrated on aca-
demic assessment. Supervision lacked a personal safety
orientation. The investigators reviewed knowledge of and
access to the written safety procedures. It was accepted
that, by the nature of ICU doctors’ work, few daily tasks
involved even momentary referral to written procedures,
even though these were available. The doctors appeared
unaware of the infection control policies and the module
that was available throughout the Trust intranet system.
There was information available on the use of gloves and
eye protection within the ICU. The ICU also provided
written posters, guidance policies on the unit and access
to eye protection. It was specifically noted that ICU safety
arrangements were generally clearly written in terms
of both policy and protocol. There was a blood-borne
virus checklist, which was reviewed regularly by unit
managers. The checklist had sections on risk assessment,
information to staff, provision of equipment and facilities,
periodic recorded checks on staff practice, and follow-up
of each incident. Any negative answer to that manage-
ment checklist developed an action plan. The provision
and maintenance of PPE were specifically allocated to an
ICU technician as a lead responsibility, and as a result a
wide range of protective equipment was readily available
and properly maintained.
Analysis of underlying causes
The investigators went on to consider underlying causes.
General causes were considered first. The investigators
found very little consideration of personal safety by the
doctors. This appeared to reflect a wider medical culture
in which health and safety has a low priority in training
[6], with the patient’s safety coming first. The doctors
reported that not only did they not routinely wear eye
protection, but neither did their medical colleagues. This
was noted to be in direct contrast to the nurses, who were
trained and inducted as a separate professional group and
who did wear eye protection in similar circumstances.
The investigators noted that role-model doctors were
apparently not using health and safety equipment
when teaching. This would potentially reinforce non-
compliance and weaken attempts to persuade more
junior medical staff to adopt good safety practice.
150 OCCUPATIONAL MEDICINE
The investigators then moved into examining possible
management causes using the National Patient Safety
Agency hierarchy of cause categories [7]. Institutional
influences were considered first. The investigators noted
that, in some organizations, senior managers have safety
objectives as part of their appraisal process. It was noted
that the NHS consultant’s appraisal handbook that was
implemented in that Trust made little or no reference to
personal safety and related health and safety issues. It was
noted that doctors’ training is managed separately from
that of other staff, and frequently involves rotation
through different work areas. Doctors in training were
unclear as to who their line manager was, as opposed to
the consultant as academic supervisor. Therefore, the
individual roles and responsibilities for the health and
safety of medical staff were also unclear in practice. As a
result, in contrast to the hierarchical nursing structure,
direction to health and safety compliance and appropriate
training was absent or reduced.
Although infection control policies identifying the
range of risks and precautions necessary for safe practice
were present, the lack of examples of specific at-risk
clinical procedures requiring goggles was considered an
underlying factor in this case. The doctors were unclear
when they had to wear goggles, but the clear perception
was that their department compared no less favourably
than other departments in the hospital, or other hospitals
they had worked in. Supervision and learning by example
were also identified as possible underlying causes, as
discussed earlier. It was interesting to note that although
eye protection was not used, protective gloves and aprons
were used when they removed the chest drain ‘because
they knew the patient was HIV positive’. This reasoning is
contrary to infection control policy, as well as Depart-
ment of Health guidelines, in that precautions should be
used universally [8].
Discussion
The Trust in question has an annual incidence of 1000
needlestick injuries and eye splash incidents per annum
reported on its staff survey. Approximately 200 of these
report to the occupational health department per year.
The background rate of HIV infection in the population
that the hospital serves is unknown, but is likely to be
higher in London than in many other parts of the UK. Of
more concern is the unknown background prevalence of
more infective agents, such as hepatitis viruses. Using this
approach has enabled the occupational health and safety
department to progress preventative strategies within the
Trust in a way that the initial factual report did not facili-
tate. In particular, the local consultants identified that
there were opportunities for improved safety training and
they were developing these as a result of this investigation.
The investigators believe that there are wider impli-
cations relating to the safety culture of doctors and that its
basis in undergraduate and postgraduate teaching war-
rants further attention. The investigators understand that
various bodies, including the Health Services Advisory
Committee to the Health and Safety Commission [9],
have attempted to encourage the further training and
engagement of doctors in health and safety. Training
modules for students have been developed to persuade
trainee doctors to think and act more proactively in
considering their own and others’ safety [10], but these
appear not to be widely implemented yet. The General
Medical Council has a role to play, and this is being
developed with ‘tomorrow’s doctors’, though they may be
in a position to do more [11]. The investigators would be
keen to hear from other occupational health and safety
departments that have performed similar analysis to see
whether their incident findings were similar, and to see
whether other Trusts have found this approach as useful.
References
1. Department of Health. Guidance from UK Chief Medical
officers’ Expert Advisory Group on AIDS: HIV Post-exposure
Prophylaxis. July 2000; 8/2.1.
2. Department of Health National Patient Safety Agency.
Doing Less Harm, version 1.0a. August 2001. http://www.
npsa.org.uk/admin/publications/docs/draft.pdf
3. HSE. Reducing Error and Influencing Behaviour, 2nd edn.
1999. ISBN 0717624528. HSG 48. http://www.hse.gov.
uk/hid/land/comah/level3/5c72542.htm; http://www.mike.
everley.freeuk.com/manage/org.html
4. Reason J. Human error: models and management.
Br Med J 2000;320:768–770. http://www.bmj.com/cgi/
content/full/320/7237/768
5. Jeffe DB, Mutha S, Kim LE. Does clinical experience affect
medical students’ knowledge, attitudes and compliance
with universal precautions? Infect Control Hosp Epidemiol
1998;19:767–771.
6. Vincent CH, Taylor-Adams S, Stanhope N. Framework for
analysing risk and safety in clinical medicine. Br Med J
1998;316:1154–1157. http://www.bmj.com/cgi/content/
full/316/7138/1154/Fu5
7. Department of Health National Patient Safety Agency.
Reporting Incidents. http://www.npsa.org.uk/static/
reporting.asp
8. Department of Health. Guidance for Clinical Health Care
Workers: Protection against Infection with Blood-borne
Viruses, 2.19:8; 3.4:9. http://www.doh.gov.uk/pub/docs/
doh/chcguid1.pdf
9. Davies R. Health and Safety Commission. Heath Services
Advisory Committee. Ensuring Doctors are Engaged in
Health and Safety. http://www.hse.gov.uk/foi/hsac55.html
10. Agius R, Smith I. Risk Assessment and Risk Reduction in
Occupational Medicine and Environmental Health—Vision
2000 Year3. http://www.link.med.ed.ac.uk/hew/v2000/
year3.html
11. Henderson M, Holland-Elliott K. Good medical practice
for occupational health. Lancet 2002;359:895.