A Culture of Safety at the CDC

By Susan Carr

I had the radio on as I drove to the market, but I wasn’t really listening until I heard “It’s very important to have a culture of safety that says, if you’ve got a problem, talk about it.” I didn’t recall ever having heard the phrase “culture of safety” outside of safety improvement circles. The speaker turned out to be Tom Frieden, MD, director of the Centers for Disease Control and Prevention (CDC), holding a press conference about a series of recent safety incidents at the CDC. The radio report I heard was a news item on WBUR, my local National Public Radio station.

Three incidents prompted the press conference:

• Personnel at the CDC’s Roybal Campus in Atlanta were exposed to “potentially viable” Bacillus anthracis, the bacteria that causes anthrax, when scientists in the lab failed to follow established protocols for deactivating the contagious materials.

• In the process of preparing a strain of influenza for a laboratory run by the U. S. Department of Agriculture (USDA), CDC personnel inadvertently contaminated it with a much more hazardous strain. The USDA lab staff members discovered the contamination only after they started to use it in research and found that it did not behave as expected. They reported the cross-contamination to CDC employees, who did not inform senior CDC leadership until six weeks later, after the anthrax incident was publicized.

• Six vials of smallpox virus, which should have been destroyed decades ago, were found at the National Institutes of Health (NIH) in Maryland. The vials had been unsecured at NIH for an undetermined amount of time. CDC and NIH immediately secured and analyzed the contents of the vials, which were dated Feb. 10, 1954, prior to the eradication of smallpox. The CDC will destroy the vials’ contents after analysis is completed, which will take up to another two weeks.

No one was harmed in any of these incidents, but they all represent serious lapses in safety protocols. At the press conference, Dr. Frieden announced measures he has taken to improve safety at CDC laboratories, including a temporary moratorium on releasing biological samples, appointment of Dr. Michael Bell as director of safety for CDC, and disciplinary action for CDC staff members who knowingly violate protocols or fail to report an incident. The NIH will search its campus to ensure that there are no other “stray materials” that should not be there, and the CDC will monitor that process.

Among all of the things that went wrong in these various incidents, Frieden said the failure to report the influenza mistake internally, immediately was the most “distressing.” When examining the behavior of individuals in these circumstances, it’s important also to examine the systems within which they work, in addition to holding them accountable for their actions, all of which is being done at the CDC. Frieden’s comments about the reporting lapse, however, may be most important indication of long-term change. They indicate that the CDC may emerge from this period of investigation and learning with a stronger culture of safety, which will be most effective in preventing similar problems—both the lapses in safety process and especially failure to report problems—in the future.

On the evening of the day I heard Frieden mention the “culture of safety” on the radio, I heard a story on the NBC Nightly News about the CDC incidents. At the end of her story, NBC’s Chief Medical Editor Dr. Nancy Snyderman reported, “There is no doubt that people are going to be held accountable, and I expect heads will roll.” I was sorry to hear no mention of the culture of safety.