Incident investigation

Overview

This guideline provides comprehensive guidance on how to conduct an investigation of incidents involving pathogens or toxins in accordance with requirements in the Human Pathogens and Toxins Act and Regulations and the Canadian Biosafety Standard. This guideline also outlines the steps of a comprehensive incident investigation process that can be followed to identify the root cause(s) of biosafety and biosecurity incidents. This allows the identification and implementation of appropriate corrective and preventive measures, which help prevent the recurrence of an incident.

Who this guide is for

• Pathogen and Toxin Licence holders
• Biological Safety Officers
• Personnel in regulated facilities

In this guide

• Preface
• Abbreviations and acronyms
• Chapter 1: Introduction
  • 1.1 Background
  • 1.2 Scope
  • 1.3 How to use the Incident Investigation guideline
• Chapter 2: Preparing for an incident investigation
  • 2.1 Investigation procedures and protocols
  • 2.2 Guiding principles of investigation
  • 2.3 The 5-step model of incident investigation
• Chapter 3: Initial response
  • 3.1 Securing the scene
  • 3.2 Reporting and notification
  • 3.3 Initiating the formal investigation
• Chapter 4: Collection of evidence and information
  • 4.1 Collecting evidence and information
  • 4.2 Establishing the incident timeline
• Chapter 5: Analysis and identification of root causes
  • 5.1 Causal factors
  • 5.2 Identifying root cause(s)
  • 5.3 Disciplinary measures
• Chapter 6: Implementation of corrective and preventive measures
  • 6.1 Identifying corrective and preventive measures
  • 6.2 Final report
• Chapter 7: Evaluation and continual improvement
  • 7.1 Measuring success
  • 7.2 Making improvements
• Chapter 8: Glossary
• Chapter 9: References and resources
• Appendix A: Biosafety-related incidents
• Appendix B: Incidents reportable to the PHAC
• Appendix C: Example incident scenario involving a student exposed to Staphylococcus aureus

View complete guide

Download PDF (6.29 MB, 87 pages)

Details and history

• Published: August 26, 2021

For assistance

Contact the Public Health Agency of Canada (PHAC) if you need assistance:

Phone: 1-613-957-1779

Email: pathogens.pathogenes@phac-aspc.gc.ca

Our service hours are Monday to Friday from 8 am to 4 pm (eastern time). We're closed on statutory holidays.

Mail:

100 Colonnade Road
Ottawa, Ontario
K1A 0K9

Service standards

We respond to mail and email within 2 business days. If we can't answer your question right away, we’ll send you an estimated date.