Table 3. Root causes in reported human pathogen or toxin exposure incidents, Canada 2017 (N=101).

Root cause	Areas of concern	Citations
		n	%
Standard operating procedure (SOP)	Documents were known but not followed	37	84
	Documents were not known by user
	Documents were not followed correctly
	Documents were not correct for the task/activity
	Documents were not in place but should have been in place
Human interaction	Labelling/placement/operation/displays of tools/equipment needed improvement	14	32
	Environmental factors within the work area needed improvement
	Workload constraints/pressures/demands needed improvement
Equipment	Equipment design needed improvement	11	25
	Equipment was not properly maintained
	Equipment failed
	Equipment was not fit for purpose
	Quality control was not performed/needed improvement
Communication	There was no method or system for communication	10	23
	Communication did not occur
	Communication was unclear, ambiguous or misunderstood
Training	Training was not developed or implemented	8	18
	Training was inappropriate or insufficient
	Training was available, but not completed
	Staff were not qualified or proficient in performing the task
Management and oversight	Supervision needed improvement	7	16
	Auditing/evaluating/enforcement of standard operating procedure needed improvement
	Auditing/evaluation/enforcement of training needed improvement
	Preparation needed improvement
	Human factors needed improvement
	Risk assessment needed improvement
	Worker selection needed improvement
Other		14	32

Abbreviations: N, total number; n, number

Notes: More than one root cause can be identified in an incident, percentages rounded to nearest whole number. Data are from the Laboratory Incident Notification Canada (LINC) surveillance system