LESSONS TO BE LEARNED
Generated from Actual Incidents at UIC
Issue No. 26 June 18, 2008
Type of Incident: Fire alarm was averted by quick thinking researcher
Details of Incident:A researcher had collected biohazardous waste, placed the
red bag waste into a secondary container and loaded the bags into a steam sterilizer/autoclave. The
autoclave door was closed and the sterilizer program was initiated. As the sterilizer filled with hot
steam and pressure, a large leak became evident around the sealed door. The researcher immediately
aborted the program but due to a delay in the programming, the sterilizer continued to release a
considerable amount of steam into the room. The hot steam condensed on the surfaces in the room
making everything very wet. The researcher had immediately called the emergency safety number (6-SAFE)
to ask for assistance. The steam leak eventually subsided and the sterilizer program stopped. No
injuries occurred during the incident.
If the researcher had not remained at the autoclave as the cycle began, the continuous leak of
hot steam would have set off the fire sprinkler head and fire alarm. The room would have quickly flooded
and caused considerable water damage to the laboratory and to rooms located on floors below the facility.
Immediate Cause: The steam leak was caused by a worn out gasket that lines
the door to the chamber of the autoclave.
Root Causes: The gasket failure of the sterilizer was the result of a lack
of thorough inspection and routine servicing and testing of the autoclave.
Corrective Actions:
Ensure preventative maintenance: call your service representative to inspect and test the autoclave on
an annual basis.
Have appropriate personal protective equipment available for loading and unloading the autoclave.
Provide documented training to individuals who will be using the autoclave; include information on
the operation of the autoclave, package of waste, proper loading and unloading techniques, and stopping
the autoclave in case of an emergency.
Know what items can and cannot be safely autoclaved.
Become familiar with quality control measures of autoclave performance such as the use of physical,
chemical and biological indicators.
Know what actions to take in case of a medical emergency (call 5-5555, UIC Police). |