1 of 5

Lessons Learned

Larry Wong, CIH, FAIHA

​

​

​

Lessons Learned | The UC Center for Laboratory Safety

​

2 of 5

National Academies - Safe Science: Improving the Culture of Safety in Chemical Academic Research (2014)

Recommendation #7: ……Association of American Universities, Association of Public and Land-grant Universities…..should work together to establish and maintain an anonymous reporting system, building on industry efforts, for centralizing the collection of information about and lessons learned from incidents and near misses in academic laboratories.

3 of 5

When Should We Develop a Lessons Learned?

  • Following:
    • Fatality
    • Injury
    • Incident
      • Damage to facilities, equipment, instruments
      • Release to the environment
    • Near Miss
      • An unplanned event that has the potential to cause, but does not actually result in human injury, environmental or equipment damage, or an interruption to normal operation (i.e., “we dodged a bullet)

​

4 of 5

Lessons Learned Format

    • Summary description of circumstances surrounding the incident. Include known contributing factors to the incident. Include photos

What happened?

    • Actions which were done properly (i.e., was trained, worked in pairs, etc.)

What went right?

    • Actions which should have been done to possibly prevent the incident

What should have been done differently?

    • Describe cause(s) for the incident

What was the cause?

    • Immediate or planned corrective actions that have or will be implemented

What corrective actions have been (or will be) taken?

    • 2 to 4 Bullet points that are to be used as the preliminary learning for all

What are the lessons learned?

5 of 5

Health & Safety Program Elements

  • Refer to Lessons Learned handout – Use as guidance to incorporate into these Lessons Learned sections:
    • What should have been done differently; and
    • What corrective actions have been (or will be) implemented