Investigating incidents that result in physical injury has long been a mainstay of OSH management systems, but how can we strive to find the direct and indirect causes of adverse health events?
The definition of an occupational accident is an identifiable, unintended incident, arising out of work, that causes physical injury or harm, whereas an occupational disease covers any disease contracted because of exposure to hazards arising from a work activity. We must note here that, in many countries, there is an official list of occupational diseases, and a disease has to be on that list to be recognised and for anyone affected to have a chance of compensation.
An accident is a singular event in time, making it easy to pinpoint when it happened. However, an occupational disease occurs over a period of time – ranging anywhere from days to years – so it is more difficult to identify. Occupational diseases are often diagnosed once pathology has set in (such as occupational asthma or noise-induced hearing loss), which means the opportunity to identify early signs and symptoms or to prevent progression of the disease process is missed.
A deeper exploration is needed to understand why occupational diseases and other adverse health events (AHEs) are not afforded the same degree of rigorous investigation as an occupational accident. If organisations do not investigate AHEs rigorously, they will fail to learn from past experiences, unsafe situations may be perpetuated, and the burden of death and disability associated with occupational disease will continue. IOSH has worked with the International Commission on Occupational Health (ICOH) to explore the investigation of AHEs, and practical takeaways from this are included in IOSH’s Blueprint.
The development and implementation of effective investigation tools has helped to reveal causative pathways and to determine remedial actions for improving control and prevention. While this is commonplace, it is less common to see such techniques applied when an occupational disease (such as work-related psychosocial stress or occupational cancer) is diagnosed. This is despite the World Health Organization and International Labour Organization’s global monitoring report Joint estimates of the work-related burden of disease and injury, 2000-2016 (2021) demonstrating the high burden of occupational disease on deaths (80.7% of all work-related deaths) and disability (70.5% disability adjusted life years) in worker populations.
What factors influence an AHE investigation?
In the early stages, occupational diseases often present with mild symptoms similar in nature to other common ailments (such as colds and flu). Workers unaware of these early warning signs fail to link the symptoms they experience with workplace exposure. For this reason, they may seek help through a GP rather than an occupational medical practitioner. GPs are not trained to make the link between AHEs and occupational causation, often leading to underdiagnosis – so a lack of understanding of the nature of occupational diseases can be a factor.
Occupational diseases can often have a long latency. Conditions such as mesothelioma have a latency period meaning that the worker may have been exposed 10, 15 or 20 years before a diagnosis is made. The worker may well have changed employer more than once in that period, making it difficult to trace back to the source of exposure. If they are working for another employer, the new employer may have little motivation to investigate.
Risk management systems often exclude the health risk.
Safety professionals who conduct the risk assessments lack training in the health aspects of workplace exposures. When completing the risk assessment, these exposures are then omitted or understated, rating them as low and resulting in a lack of recognition of latent risk.
If organisations do not investigate Adverse Health Events rigorously, they will fail to learn from past experiences
Lack of empowerment among workers can also be an issue. If workers are not familiar with the health effects of workplace exposures, they will not report these to the OSH team. And if they are not represented on the risk assessment team, their voice on signs and symptoms experienced by their colleagues is missed.
Both safety professionals and healthcare professionals (such as doctors and nurses) often lack expertise around how to investigate occupational diseases. Training courses very often focus on the investigation of an accident, which is more easily identified. The investigation of an occupational disease or any other AHE differs from that of an accident because the condition needs to be brought to the attention of the professionals, who will then investigate the cause and attempt to identify a link to workplace exposures.
There is sometimes a poor understanding of exposure through the manufacturing/production process and how risk changes as chemicals change. Many chemicals are harmless but, once changed through the manufacturing process, they become highly toxic. One such example is hexavalent chrome, which is a valance state of chrome and a known carcinogen in the hexavalent state. If this is not understood, the early nasal symptoms can be passed off as a common cold. Exposed workers can include welders and electroplaters.
Finally, a lack of consultation and collaboration between OSH professionals often leads to a missed opportunity to link an accident with an underlying health condition (for example, a finger laceration could be caused by Parkinson’s tremors and, if missed, may well recur).
Key takeaways for practitioners involved in AHE investigations
- Recognise your limitations and include other team members and experts to assist your investigation where required.
- Take a multidisciplinary approach, where disciplines collaborate to determine both direct and indirect causes of an AHE.
- Always be suspiciousa health concern could be related to workplace exposure.
- Build a broader preventative culture which is founded on worker health and wellness.
- Improve risk assessments where possible to better address health-related issues through greater knowledge and an enhanced understanding of health hazards.
How can the investigation of AHEs be improved?
Risk assessments need to better address the health effects associated with workplace exposures. For example, they need to follow chemicals through the manufacturing process and ensure the ‘hazardous phases’ of chemicals are not missed.
There is no single, prescribed group of people required to investigate an AHE – it is entirely context-dependent. Third-party expertise may be a vital component in certain cases. Most of the time, a multidisciplinary team will be required to understand the complexities of the root causes.
Obtaining a comprehensive occupational exposure history from workers is a key tool for diagnosing occupational disease. Where possible, new starters should be encouraged to bring their past exposure history with them from their previous employers.
Understanding the impacts of chemicals on health should motivate us to find healthier alternatives – for example, replacing solvent cleaning with water-based cleaning, or avoiding 12-hour shift rotations given the negative health impacts which have been demonstrated. OSH practitioners may be familiar with the term ‘safety by design’, but this concept needs to extend to ‘health by design’.
Training courses should be improved so they cover the unique characteristics of the investigation of AHEs. These courses need to promote the need to establish root causes and not just settle for simple solutions.
If workers are included more, we have a better chance of spotting AHEs. The nature of early warning signs is often similar to common colds and other primary healthcare issues, resulting in them being discounted. Educating the workforce would help them to recognise relevant signs and symptoms. Ensuring that they understand the relevance of the signs and symptoms associated with their work-related exposures would mean that they are informed and can report these sooner.
The burden of disease in the workplace far outweighs the impact of injuries. It is essential therefore that AHEs are investigated, and that the root cause and contributing factors are identified and addressed to ensure that future disease is prevented.
As professionals, we need to improve the investigation of all AHEs with the intention of identifying the cause and implementing tighter controls to prevent exposure.
REFERENCES
World Health Organization, International Labour Organization. (2021) WHO/ILO joint estimates of the work-related burden of disease and injury, 2000-2016: global monitoring report. (accessed 21 February 2024).