From: Ralph Stuart <rstuartcih**At_Symbol_Here**>
Subject: Re: [DCHAS-L] Glassware injury lesson learned report?
Date: Mon, 6 Jul 2015 08:03:16 -0400
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>
Message-ID: 9AA2FEDB-17E0-4526-A62A-FD37CA9DEB8C**At_Symbol_Here**
In-Reply-To <02e701d0b4ea$d355b1e0$7a0115a0$**At_Symbol_Here**>

Thanks to everyone for sharing their experiences with and Lessons Learned with regard to glassware events in labs. They will help me provide context for this issue in the training. I did find a good review article on this topic at

With regard to:
> >I think it is tragic that we do NOT have a Lessons Learned database where reports such as the dozen just posted can be placed and we can learn.

This is a complicated idea to implement with cultural challenges as well as technical ones. One of the first stories we learn is about the Boy Who Called Wolf, so people develop an early aversion to sharing bad news. One of the key points I make in lab training is that the first thing that people learn about fire alarms in kindergarten (never touch a fire alarm) is no longer applicable. Consistently, there is a look of surprise in the audience when that sinks in.

There are still technical challenges in terms of defining what events and information should be included in such a database and how to make it useful, but the cultural challenges are at least as interesting to address.

- Ralph

Ralph Stuart

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