Lessons Learned─Splashing Incidents of Methanol and ortho-Chlorobenzaldehyde into Eyes and Faces Due to Accidental Detachment of Luer Slip Syringes and Needles

Abstract

This study provides details of two incidents involving the splashing of chemicals (methanol and ortho-chlorobenzaldehyde) from Luer slip syringes into students’ eyes and faces in chemistry laboratories. The methanol incident was directly caused by unsafe acts, specifically the inappropriate use of a Luer slip syringe without adjusting the position of the clamp, which remained elevated. Additionally, the incident was a result of an unsafe condition, as the safety glasses wore by the individual were not designed as over-the-glass safety glasses, creating a gap between the student’s face and lip of the safety glasses, thereby allowing methanol to reach the student’s eyes. Unsafe acts were identified as the direct causes of the ortho-chlorobenzaldehyde incident. These acts included using an inappropriate Luer slip syringe, exerting force on a long syringe needle, conducting syringe operations outside a fume hood, and neglecting to wear appropriate safety glasses and a lab coat. Furthermore, an unsafe condition involved the inappropriate positioning of a flask within a fume hood. Consequently, detaching a needle from the Luer slip syringe resulted in the scattering of chemicals reaching the student’s face and eyes. A method that enables the multifaceted exploration of the causes of human errors and facilitates the development of comprehensive solutions was used to identify 16 root causes of human errors and 11 preventive measures for the ortho-chlorobenzaldehyde incident. The lessons learned from the two incidents contribute substantially to preventing the recurrence of similar syringe incidents and reducing the risks associated with syringe operations in chemistry laboratories that handle hazardous/toxic chemicals.