McMaster University

McMaster University

Update logo.Laboratory Audits

All biohazard labs are audited by the Research Compliance Auditor (link on left) using the combined set of criteria. The combined set of criteria lists the references to the Standards and gives an expected method of local implementation within the Supervisor's laboratory.

It is the 'combined set of criteria' document which gives the details of what is expected. It is strongly recommended that the 'combined set of criteria' be reviewed within the laboratory prior to the audit so that any questions can be addressed beforehand.



A printable check/summary sheet is here.

Level 1 criteria are assessed according to the Canadian Biosafety Guideline (1st Ed). Where standards were not found but the practice is implemented, equivalent standards were chosen from the Laboratory Biosafety Guidelines (3rd Ed), the WHO Laboratory Biosafety Manual (3rd Ed) and the CDC/NIH Biosafety in Microbiological and Biomedical Laboratories (5th Ed).

Level 2 criteria are assessed according to the Canadian Biosafety Standard (2nd Ed).

Level 3 criteria are assessed according to the Canadian Biosafety Standard (2nd Ed).

Plant pest labs (in vitro to greenhouses, where applicable) will also be audited according to the Containment Standards for Facilities Handling Plant Pests.

Aquatic pathogen labs (in vitro and in vivo, where applicable) will also be audited according to the Containment Standards for Facilities Handling Aquatic Animal Pathogens.

As of August 25, 2014, the following laboratory audit schedule will apply:

  • Containment Level 1 laboratories to be audited at minimum every three years
  • Containment Level 2 laboratories are to be audited at minimum every two years
  • Containment Level 3 laboratories are to be audited annually

 

Laboratory audit results are entered into the BUP system and an email sent to the Supervisor to log in and view/acknowledge the report(s). Due to the nature of shared spaces and a variable number of rooms, a Supervisor may be required to acknowledge more than one audit report. Every effort is made to audit a Supervisor or a group in a reasonable time frame.The Supervisor is expected to acknowledge within 30 days and is expected to have all items addressed within a reasonable timeframe.

Audit results are reviewed by the PBAC each month. Trends in audit items are reviewed annually to allow for root cause analysis and improvement of the program. Feedback by individuals is always welcome.

View the compliance data! >> When reading the data, consider that audits are conducted every 2 or 3 years depending on the containment level of the laboratory. Also consider that for each criteria, we may be looking for multiple different items. Please forward your queries to the Research Compliance Auditor (link on left).

Frequently Asked Questions

Why am I audited so frequently?

Due to the nature of lab space, you may receive multiple audit reports over a few weeks. Each Level 1 PI is audited every three years and each Level 2 PI is audited every other year.

If you are in the HSC building, the auditor also completes a JHSC workplace inspection at the same time. In this case you will receive one email to acknowledge each of the Biosafety Audits and one email with a JHSC Inspection report.

For all biohazard labs, we now have a 6 month followup process. In this case, the visit is only to verify that the items outstanding on the initial audit have been completed. If you have addressed all the items in the original report, there should be no preparation required.

The audits and inspections you receive/perform include the following:

  • Biosafety audits
  • Biosafety audit follow-ups
  • Joint Health and Safety Committee workplace inspections
  • Supervisor quarterly workplace inspections
  • Health Physics Inspections
  • AREB Audits
  • regulatory inspections

 

The items in the audit report do not originate from my laboratory. What do I do?

If the item in question is in space for which you are directly and solely responsible, it is your responsibility to address it.

If the item in question is in an equipment or common room, for which you are directly and jointly responsible, it is your responsiblity to consult with the other responsible supervisors to manage the corrective actions. It is recommended that you copy/paste the audit report into an email if you require to forward the information.

I'm the only one receiving audit reports for rooms which I share with others. What do I do?

If the room is an open-concept lab where you are alotted a defined area of space, only that defined area for which are solely responsible would have been audited. If this is not the case, please contact us so we may follow up.

If the room is an equipment room where there is no defined space allotted to you, all biohazard supervisors who use that room should be on the report itself. Each supervisor gets their own email notification, but the report should include all the names. If this is not the case, please contact us so we may follow up.

In the case of equipment rooms, every effort is made to include identifying features (BSC's numbers, names on incubators etc) so that the supervisor can easily identify the corrective actions they are required to take. If the item is something generic like loose floor tiles or damaged benching, it is up to the group who use the room to follow their department or unit arrangements to have the item addressed.

Updated 09-August-2018

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