Comparision of Healthcare Injury Rates in the US and UK

This blog has commented several times about the very high injury rate in healthcare compared to other industries and has repeated the statements made in the Executive Summary of the 2009 NORA report “State of the Sector Healthcare and Social Assistance.

The HCSA [Healthcare and Social Assistance] sector is burdened by the historical and entrenched belief that patient care issues supersede the personal safety and health of workers and that it is acceptable for HCSA workers to have less than optimal protections against the risks of hazardous exposures or injuries. Because patients and providers share the healthcare environment, efforts to protect patients and providers can be complimentary, even synergistic, when pursued through a comprehensive , integrated approach.

An OSHA press release, discussing statistics from the BLS for nonfatal occupational injuries and illnesses requiring days away from work in 2010 in healthcare stated that  
... the incidence rate for health care support workers increased 6 percent to 283 cases per 10,000 full-time workers, almost 2 1/2 times the rate for all private and public sector workers at 118 cases per 10,000 full-time workers. The rate among nursing aides, orderlies and attendants rose 7 percent, to 489 per 10,000 workers. Additionally, the rate of musculoskeletal disorder cases with days away from work for nursing aides, orderlies and attendants increased 10 percent to a rate of 249 cases per 10,000 workers.  

Assistant Secretary for the department's Occupational Safety and Health Administration Dr. David Michaels issued the following statement in response:

"It is unacceptable that the workers who have dedicated their lives to caring for our loved ones when they are sick are the very same workers who face the highest risk of work-related injury and illness. These injuries can end up destroying a family's emotional and financial security. While workplace injuries, illnesses and fatalities take an enormous toll on this nation's economy – the toll on injured workers and their families is intolerable...."

It is interesting to compare the situation in the US with the UK to determine if this lack of regard for employee safety is an industry or US problem or a more global issue. Both the US and UK are modern industrialized countries with comparable levels of healthcare technology and life expectancy (79 and; 80 yrs for the US and UK respectively), though the former is largely private institutions and the latter is a mix of National Healthcare Service (NHS) and private hospitals.

In the US occupational injury statistics are collected and reported by the Bureau of Labor Statistics (BLS) and in the UK by the Health and Safety Executive (HSE). The HSE has a webpage dedicated to the healthcare sector and has issued a report Health and safety in human health and social care in Great Britain, 2013 from which most of the UK data is drawn from.

 In the UK the rate of non-fatal injuries in healthcare (SIC 2007 divisions 86, 87, 88) has been slowly decreasing over time. The chart below shows the estimated averaged numbers of all self-reported workplace injury and of non-fatal injury with over three day absence, for people working  in health and social care in the last 12 months.




If we compare the UK and US numbers for 2010, the injury rate requiring time off was 2,830 per 100,000 workers for the US compared to the UK all non-fatal injuries 2,500 and 1,000 for injuries requiring more than 3 days off work. 

The two numbers though are not directly comparable since the US numbers are based on taking time off, whereas the UK numbers are based on both any reported non-fatal injury and non-fatal injuries taking three or more days off. It is reasonable to assume that the UK any non-fatal injury requiring time off would be between these lines. This data suggests that the non-fatal injury rate for UK healthcare personnel is significantly less than their US based colleagues, but because of the different data formats we are unable to say by how much less.

One of the more striking aspects of the US summary was the high rate of injury in healthcare compared to general industry. The same trend is seen in the UK.  The tables below based on the labor force survey (LFS) clearly shows that people in the caring personal services sector of healthcare are much more likely to suffer an injury and take time off work because of that injury than the general workforce. 

Non-fatal injuries vary with occupation





 The injury rate rate for caring personal services was (0.28/0.17=) 1.65 times greater than general industry compared to almost 2 1/2 times in the US indicating that this industry is more injury prone on both sides of the Atlantic.

We should be cautious about drawing too many conclusions from these numbers since the data may have been collected in different ways, with different assumptions made and the analysis above is only a cursory review of published summaries and so as Mark Twain credited Disraeli with saying "There are three kinds of lies: lies, damned lies and statistics."

However, overall it appears that the UK has a lower injury rate in healthcare compared to the US. In part this difference may be because OSHA's enforcement arm is needlessly cash limited, as discussed previously in this blog, and OSHA is limited to the size of the fine it can issue. Consider for example where an employee is fatally injured. Section 17 of the Occupational Safety and Health Act of 1970 sets the fine.

Any employer who willfully violates any standard, rule, or order promulgated pursuant to section 6 of this Act, or of any regulations prescribed pursuant to this Act, and that violation caused death to any employee, shall, upon conviction, be punished by a fine of not more than $10,000 or by imprisonment for not more than six months, or by both; except that if the conviction is for a violation committed after a first conviction of such person, punishment shall be by a fine of not more than $20,000 or by imprisonment for not more than one year, or by both.

OSHA's fines and the associated publicity are more embarrassing to organizations than having any real financial impact. In comparison, the HSE fined a cleaning company £175,000 ($281,000 at today's exchange rate) after a hospital porter was killed by an industrial waste compactor. 

The problem with small OSHA fines has been recognized by OSHA others and the Protecting America's Workers Act was introduced to Congress in January 2011 and would have increased OSHA fines, but it was not passed and the chance of it passing in the new future appears to be small.

A recent RAND report  suggests that the UK may have a stronger culture of workplace safety than the US, finding that in 2010, the fatality rate in the UK was about 1/3 the rate in the US. In construction the rate was about ¼ the US rate, a difference that had grown substantially since the 1990s. ..., lower rates were associated with high-level management attention to safety issues and to in-house preparation of “risk assessments.”  The authors concluded "Although work fatality rates have declined in the US, fatality rates are much lower and have declined faster in recent years in the UK. Efforts to find out the reasons for the much better UK outcomes could be productive."

Annotated PELs from OSHA

OSHA has long recognized that its permissible exposure limits (PELs) for gases and vapors are in need of an update. Many of them have not been updated since the PELs were first promulgated over forty years ago. As this blog has commented previously, OSHA faces an enormous administrative burden to produce updated or new standards.

OSHA has just published annotated standards in which the OSHA PELs are placed side by side with the NIOSH Recommended exposure limit (REL) and the ACGIH threshold limit values (TLVs). As discussed previously, the OSHA PEL is a legal maximum exposure limit, whereas the NIOSH REL and the ACGIH are values set based on the best available science but are considered recommendations as opposed to legal limits.(Note in some jurisdictions outside the US, the ACGIH TLVs are legally enforceable, not in their own right, but because the legislature in that country/province/territory etc. has adopted them into their law).

In OSHA's own words:

OSHA also created another new web resource: the Annotated Permissible Exposure Limits, or annotated PEL tables, which will enable employers to voluntarily adopt newer, more protective workplace exposure limits. OSHA's PELs set mandatory limits on the amount or concentration of a substance in the air to protect workers against the health effects of certain hazardous chemicals; and OSHA will continue to enforce those mandatory PELs. Since OSHA's adoption of the majority of its PELs more than 40 years ago, new scientific data, industrial experience and developments in technology clearly indicate that in many instances these mandatory limits are not sufficiently protective of workers' health. 

"There is no question that many of OSHA's chemical standards are not adequately protective," Michaels [David Michaels, Assistant Secretary for Labor, Occupational Safety and Health] said. "I advise employers, who want to ensure that their workplaces are safe, to utilize the occupational exposure limits on these annotated tables, since simply complying with OSHA's antiquated PELs will not guarantee that workers will be safe."

The annotated PEL tables provide a side-by-side comparison of OSHA PELs for general industry to the California Division of Occupational Safety and Health PELs, National Institute for Occupational Safety and Health recommended exposure limits, and American Conference of Governmental Industrial Hygienist threshold limit values. They offer an easily accessible reference source for up-to-date workplace exposure limits, which are available at http://www.osha.gov/dsg/annotated-pels/index.html.

Under the Occupational Safety and Health Act of 1970, employers are responsible for providing safe and healthful workplaces for their employees. OSHA's role is to ensure these conditions for America's working men and women by setting and enforcing standards, and providing training, education and assistance. For more information, visit http://www.osha.gov.

The annotated PELs are available for not only gases and vapors but also solids. The annotated PELs are drafted around the PELs published in 29 CFR 1910.1000 and its tables Z-1, Z-2 and Z-3. The Annotated PELs are available at Z-1, Z-2 and Z-3.

The NIOSH RELs and ACGIH TLVs have been in use for many years and are widely respected. However many organizations have not understood the difference between them and the PELs and have relied solely on the OSHA PELs, as the prime means to protect their people, because of the legal status of the latter. These annotated PELs will hopefully encourage employers to use the RELs and TLVs with OSHA's blessing and so create a safer work environment. 

Public Citizen Report that Insufficient OSHA Inspections Leave Healthcare Workers Unprotected

On July 17th 2013, Public Citizen, a national non-profit organization released a report titled "Health Care Workers Unprotected. Insufficient Inspections and Standards Leave Safety Risks Unaddressed."  The report cites the a CDC article that shows that Healthcare is the fastest-growing sector of the U.S. economy, employing over 18 million workers. Women represent nearly 80% of the healthcare work force. Health care workers face a wide range of hazards on the job, including needlestick injuries, back injuries, latex allergy, violence, and stress. ... The high rate of injuries among healthcare workers has been discussed before on this blog, especially with regard to chemical exposures.

Cases of nonfatal occupational injury and illness among to healthcare workers are among the highest of any industry sector. By contrast, two of the most hazardous industries, agriculture and construction, are safer today than they were a decade ago.  This at a time when healthcare spending and the number of people employed in healthcare is increasing.

Public Citizen places the blame in OSHA's lack of inspection and lack of suitable ergonomic standards applicable to healthcare and the following statistics show that they have a good point.

Industry	No. Employed	No Injuries	No Fatalities	No. Inspections
Construction	9.1 million	74,950	744	52,179
Manufacturing	14.1 million	127,140	329	19,566
Healthcare and Social Assistance	18.9 million	176,380	141	2,504

The number of inspections in healthcare and social assistance is proportionately much smaller than in either manufacturing or construction. Some of this difference is due to the more severe injuries in manufacturing and construction, but even when comparing the relative rates of fatalities the report says that OSHA conducts fewer than 1/4th as many inspections in health care as in construction in proportion to the number of fatalities.

This blog has also commented previously on the lack of OSHA inspections, due to a lack of resources, even though the revenues from the additional inspections would almost fully reimburse the treasury.

The other point that the Public Citizen report makes is that there are insufficient standards relevant to healthcare, especially ergonomics. This blog has also discussed previously about how it is more difficult for OSHA to promulgate new standards and regulations compared to many other government agencies. If there are not applicable standards available, then OSHA must use the General Duty Clause in order to prosecute unsafe work practices. The additional evidentiary burden makes these prosecutions few and far between.

As Assistant Secretary of Labor David Michaels said "It is unacceptable that the workers who have dedicated their lives to caring for our loved ones when they are sick are the very same workers who face the highest risk of work-related injury and illness."