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Guidelines for Writing a Case Study
Michael G. Koehler*
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ABSTRACT: Case studies are an effective publication method
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used to document the facts and analysis of a specific observation or
incident. The content and format of a case study can vary
depending on several factors, including the purpose of the case
study, the degree of analysis available at the time of the report, the
derived lessons learned, and any recommendations. This
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commentary outlines the guidelines for writing an effective case
study.
■ INTRODUCTION
Case studies, also known as case reports, are commonly
associated with medical, law, and business publications. They
are used to document, share, discuss, and often question the
details on a specific case. One historic example is the case study
published in 1817 by James Parkinson on the neurological
malady that would eventually bear his name.1 Similarly, a case
report in 1981 presented the cases of 5 young men in Los
Angeles with pneumocystic pneumonia.2 This report contained
seven brief paragraphs that described the patients’ symptoms,
treatments, and outcomes. Unlike a formal research report, no
analysis of the cases or conclusions were presented. This report
would be the first published documentation of acquired
immune deficiency syndrome, AIDS.
In law, a system which relies on the precedents of court
rulings, legal cases are meticulously documented and serve as a
basis for rulings in future cases. An example of this is the
Miranda v Arizona case ruling by the U.S. Supreme Court in
1966.3 This landmark legal case documents the facts and
analysis of a case heard by the U.S. Supreme Court.
Commonly known as the Miranda Rights, the ruling for this
case has been referenced numerous times in other cases
involving the rights of the accused.
Because case studies usually describe a single case or small
number of related cases, they usually do not adhere to the
rigors of the scientific method where extensive experimental
data is analyzed, hypotheses are tested, and conclusions are
presented. In fact, many case studies do not report a
conclusion. Instead, they are facts reports or evidence reports,
documenting the factual evidence only, allowing the readers to
develop their own critical analyses, connect with their own
cases, and establish their own conclusions. Case studies are
often used as an educational tool, allowing students to review
facts, think critically, and develop hypotheses and conclusions
based on their own knowledge and experiences.
© 2020 American Chemical Society
3 ACS Chem. Health Saf. 2020, 27, 3−7
Commentary
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Article Recommendations
The information in a case study would usually not qualify for
publication as a research report for many scientific journals
because it often lacks the rigors of the scientific method and
data analysis. However, there is tremendous value in
documenting and sharing the data, description, and analysis
of a single observation or incident. For example, the
publication of incident reports involving chemical health and
safety information presents an opportunity to prevent future
similar events by alerting other chemical practitioners of
hazards, adverse outcomes, or new best practices. The case
studies published by the U.S. Chemical Safety and Hazard
Investigation Board (CSB) are an excellent example of safety-
related case studies.4 The CSB case studies are shorter, more
focused analysis of accidents involving chemicals, including a
discussion of relevant accident prevention practices. The
National Center for Case Study Teaching in Science (NCCSTS)
at the University of Buffalo has an extensive collection of case
studies, both fiction- and reality-based.5 These case studies
were intended as teaching tools and often include a study guide
to engage students in learning activities and discussions.
As an investigator of chemical accidents, I have encountered
numerous forms and formats for documenting the information
on chemical and environmental accidents. In addition to CSB
and NCCSTS case studies, other styles and formats include
expert reports used for litigation, environmental reports
documenting chemical spills, and police reports of crimes
and accidents.
For case studies presenting information on chemical health
and safety, it will be advantageous to have established
Received: December 10, 2019
Published: January 15, 2020
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ACS Chemical Health & Safety
guidelines for content and style that address questions such as
the following:
• What should be reported?
• What should be included in the documented case study?
• When should the case study be published?
• What is the framework and format for a case study?
■ WHAT SHOULD BE REPORTED?
Answering this question depends on the intended use for the
case study. When educators and their students are the intended
audience, the study often includes a brief scenario of a
chemistry incident and a list of exercises and discussion
questions. Most CSB case studies include the description of
the accident, an analysis of the factors involved in the incident,
a list of Key Lessons, and recommendations for operational
adaptations. Because this journal intends to include case
studies as an accepted form of publication to disseminate
health and safety information across the chemistry enterprise,
the author recommends that chemical incidents, near misses,
and other reports where chemical health and safety is discussed
should be reported.
To understand what to report, it is important to differentiate
between a research report and a case study. A research report is
the result of an investigation which follows the scientific
method, establishing and testing a hypothesis. The research
report format follows the scientific method, beginning with the
presentation of the hypothesis followed by the data and
analysis which are used to validate the hypothesis. The
research report presents a discussion of the results and a
conclusion regarding the hypothesis. The ACS Guide to
Scholarly Communications (formally known as the ACS Styles
Guide) provides guidelines for content and format in research
reports.6
By contrast, a case study is a report on a specific observation
or incident (or a limited number of related observations or
incidents). Some case studies, such as facts reports, will simply
report the facts and evidence of the case without analysis or
conclusions. Other case studies can include an analysis,
discussion, conclusions, and recommendations.
The content of a case study should be a report of an
interesting observation or incident which disseminates the
information on the event. Case studies are meant to notify,
alert, or educate the reader with information on risks and
approaches to similarly situated circumstances, best practices,
and recommendations. Although case studies are not research
reports, they are scientific reports. As such, case studies should
be based on real cases involving chemical accidents, health and
safety practices, innovative health and safety programs, and
other health and safety relevant cases.
■
WHAT SHOULD BE INCLUDED IN A CASE STUDY?
Since case studies are not research reports, the content of a
case study is less rigorous and may vary considerably
depending on the purpose of the report. The content of a
case study will also vary depending on the information
available at the time of reporting.
Some case studies will be facts reports, including only fact-
based data, evidence, and observations. Facts reports often
omit an analysis, discussion, or conclusion. Commonly,
medical case studies are facts reports, or evidence-based studies.
They list only observations and outcomes, with no analysis or
discussion. Many investigations of chemical accidents produce
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pubs.acs.org/acschas Commentary
several facts reports including police reports, medical reports,
autopsies, and photographic/evidence reports without dis-
cussion or conclusions. These reports are often published soon
after an accident has occurred to immediately collect and
document the evidence, aid an investigation, or alert the public
of a potential hazard.
Other case studies will include an analysis of the facts and
present a discussion, conclusions, lessons learned, and
recommendations. An excellent example of this is found in
the case studies published by the CSB. In CSB case studies, a
specific incident is summarized at the conclusion of an
investigation, with sufficient detail to allow others to examine
the incident, establish an understanding of the contributing
causes, learn from the experience, and implement recom-
mendations to prevent recurrence.
Expert reports are case reports written by expert witnesses for
legal cases. An expert witness is recognized by the courts to be
qualified to render opinions and testify in legal cases based on
their knowledge, education, and experience. Expert reports will
include a discussion of the case, an examination of the factual
evidence and data, and “more likely than not” opinions on the
interpretation of the data. It is important to explain the
scientific basis for all opinions. Unless restricted by court order,
expert reports and the expert’s opinions are considered public
records and referenced as legal documents.
At a minimum, any type of case study should present the
background of the case, a description of the observation or
incident, and relevant data and facts gathered in the
investigation. If the case study is reported at the conclusion
of an investigation, then the analysis, discussion, lessons
learned, and recommendations can be included. It is
recommended that case studies submitted to this journal for
publication always be based on real incidents, not hypothetical
scenarios.
■
WHEN TO REPORT?
A facts report is often published early after an incident. In cases
involved in the transportation of chemicals, the National
Transportation Safety Board (NTSB) will often issue a facts
report within a few days of an accident. Since time may prevent
a full analysis, these case studies may exclude an Analysis or
Conclusion section in the report. In these reports, the studies
should state clearly that it is a facts report based on information
available at the time.
CSB case studies are issued after the investigation has
concluded. For example, in the case of the Texas Tech
University chemistry lab explosion, the incident occurred on
Jan 7, 2010, and the CSB case study was released more than a
year later on October 19, 2011.7 Generally speaking, case
studies that are facts reports should be reported soon after the
incident to promote early dissemination of information, alert
the public, and encourage discussion of the incident. When a
case is still being investigated, the report should clearly state
that the report is based on information available at the time, in
an ongoing investigation. Reports that include analysis, lessons
learned, and recommendations should be published only after
the investigation has been completed.
■
WHAT ARE THE FRAMEWORK AND FORMAT FOR
A CASE STUDY?
A case study is a detailed documentation of a specific
observation, incident, or situation. To report these details,
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ACS Chemical Health & Safety
authors conduct an investigation into the incident and gather
the facts. The process for conducting an investigation is a
lengthy discussion and beyond the scope of this commentary,
but for completeness a case study should always consider the
“4-C’s”: chemicals, chemistries, chemists, and conditions.
Chemicals. Case studies related to chemistry should
contain information on the chemicals involved. This
information should include the chemical name, Chemical
Abstract Service Registry Number (CASRN), purity, source,
and packaging. Safety Data Sheets (SDSs) from the
manufacturer should be the primary source of this information,
and the SDSs for all relevant chemicals involved in the incident
should be listed as references. Additional authoritative
information, such as PubChem Laboratory Chemical Safety
Summaries (LCSSs), can be supplied as needed.8
Chemistry. Details regarding chemical reactions (including
information about intermediates), chemical processes, and
procedures should be included. This information may contain
process or procedural documentation, and thermodynamic and
kinetic data. The discussion should note deviations from the
documented processes and procedures. To describe these
deviations, it is important to conduct interviews with witnesses
to ascertain details of actual processes and procedures used in
the study.
Chemists. Human factors are often key to a case study.
When describing the chemists, it is not necessary to identify
the chemists by name, but it is important to document the
chemists’ work experiences, training, knowledge base (chem-
istry and safety), and supervision. Many case studies relate to
the lack of training or inexperience with the chemistries as
contributing factors to an incident. Therefore, what the
chemists did not know is just as important as what the
chemists knew.
Beside the intellectual and mental state of the chemists, it is
important to document the actions of the chemists, including a
timeline for the actions. It is important to report facts, not
opinions. For example, the training record of the chemist is
factual information. However, stating that the chemist was
improperly trained is an “opinion” and should not be included
unless a final report has rendered that as an opinion in the
conclusion section of the report. If statements of opinion are
included, these should be clearly identified as such in the
conclusion section.
Conditions. A case study should document relevant
conditions in which an incident occurred such as environ-
mental factors, laboratory hygiene, room occupancy, and
equipment conditions. The conditions should report factual
data, not opinions. For example, stating “the room was 85
degrees F”, is factual data. However, stating “the room was
excessively hot” is an opinion. Opinions should only be
discussed in the conclusion section and clearly identified as
opinions. Personal protective equipment (PPE) in use at the
time of the incident should be included. Conditions may also
include regulatory compliance such as the presence or absence
of records and documentation. SDSs, standard operating
procedures, equipment manuals, and posted safety information
should also be considered under conditions.
■ FORMAT FOR A CASE STUDY
Since a case study is a scientific report, consideration should be
given to the sections to include and the structure of the report.
Similar to all publications, a case study will have required
sections and optional sections. For example, all case studies
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should contain a title, list of authors, abstract, background,
description of the incident, and a clear presentation of relevant
evidence and data. However, not all case studies will include an
analysis or list of recommendations. To inform the reader of
the manuscript type, the title should include the words Case
Study or Case Report.
Most scientific publications are written with a standard
format. The ACS Guide to Scholarly Communications describes
the standard format for reporting original research as
consisting of: Abstract, Introduction, Results and Discussion,
Methods and Materials, Conclusions, Acknowledgments, and
References.6 This format parallels the methodology of the
scientific methods, where hypotheses are presented, experi-
ments are conducted to test the hypothesis, and conclusions
are presented. Since most case studies are not the result of
original research, the structure and format for the published
case study is different. A basic structuring format for a case
study is offered here.
Title. The title of the report should begin with Case Study:
or Case Report: followed by a brief description of the case. For
example, Case Study: Medical oxygen tank explosion at Rosewood
Hospital in Chicago.
Authors and Affiliation. The list of authors and affiliation
should include those who contributed substantially to the
report, using the style of the ACS Guide to Scholarly
Communication.6
Abstract. The abstract should be a brief summary of the
report. The abstract should include a description and date of
the observation or incident, the information contained in the
report, and, if available, the key findings and conclusions.
Keywords. To facilitate data indexing and computerized
searches, keywords should be included. Since the title of the
report includes Case Study, it is not necessary to repeat this
term in the list of keywords.
Introduction. A brief introduction of the case should be
presented which describes the case. The case description
should inform the reader on what happened and why reporting
of the incident in the case study is significant. The introduction
should also present the status and/or limitation of the report.
For example:
This case study, discussion, conclusions, and recommendations
are based on a review of the evidence, relevant documents, witness
and expert reports, as well as related regulatory, chemical safety,
and scientific literature available to the authors. All conclusions are
held to a reasonable degree of scientific, engineering, and technical
certainty. It is recognized that new information may become
available as a result of additional evidence and information related
to the incident described in this report. As such, this case study may
be supplemented as required based upon additional evidence and
information.
Background. Each case study should begin with a brief
discussion of relevant background information. Case studies
reporting an incident should include a brief review of the 4-Cs
(chemicals, chemistry, chemists, and conditions) to help frame
the case. The background should be presented chronologically
to inform the reader of the sequence of events which preceded
the observation or incident.
The background section should also include a statement
regarding the status of the investigation. Many case reports will
be published before all the evidence, data, and analysis is
available. For these reports, the background should acknowl-
edge that the investigation is ongoing, and the report may be
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ACS Chemical Health & Safety
supplemented and amended based on new evidence and data
made available to the investigators.
Description of the Incident/Observations. The de-
scription of the incident should be fact-based. It should be a
chronological reporting of the incident with supporting
evidence, data, and witness statements which continue building
on the information in the background section. Facts and data
should be reported in a way that the reader will understand the
context, its relevance to the study, and the credibility of the
information. Photographs and postinspection analytical data,
including the source of the information, should be included in
this section of the report. This information provides objective
information for the study. Information obtained from witnesses
should also be considered, while recognizing that witness
testimony is a subjective interpretation of the events. Legal
rights, permission, and court ordered restrictions to publish
photographs, data, and witness testimony must be considered
before including this information in a report. The 4-C’s should
be considered when describing the incident/observation to
ensure completeness.
Incident Analysis (Optional). Not all case studies will
include an analysis of the incident. In some reports, only
factual information will be included without an analysis or
conclusion. As was reported on the first reported AIDS cases,
the study only presented the signs, symptoms, treatments, and
outcomes with little analysis or discussion on the disease.
These early stage facts reports aim to alert the public, promote
discussion, and encourage further investigation where appro-
priate. In these reports, the analysis may be excluded.
Case studies that are produced after a full investigation has
been conducted, analyzed, and reported are expected to
include all aspects of the investigation, including the incident
analysis. This section may include a discussion of incident
analysis tools used in the investigation, such as bowtie analysis,
failure modes and effects analysis (FMEA), and the 5-whys
analysis.
In case studies which include an analysis, the objective is to
assist the reader in the interpretation of the relevant facts while
remembering that a case study is not a formal research report
aiming to establish or confirm a theory. While the evidence
presented may support a hypothesis, the evidence seldom
validates a hypothesis since it relates to a single observation.
This distinction delineates the case study from a research
report where the information is validated through extensive
experimentation and multiple observations. The analysis
should also be presented so that others can understand the
reasoning and how alternative explanations were considered.
Where multiple occurrences of the incident are known, a
comparative analysis may be included. The analysis should also
distinguish this case from other similar operations where the
reported outcome was not observed.
Key Lessons (Optional). For case studies which document
the conclusion of a full investigation, the report should include
a list of Key Lessons. These lessons are the learnings from the
study and act as a framework for recommendations to other
practitioners with similar cases.
Case studies developed for educational purposes may wish
to have the students develop Key Lessons. Thus, when used as a
teaching tool, this section can be left for the students to
develop. When used as a teaching tool, the Key Lessons may
also be replaced with Activities and Discussion Guidelines.
Conclusions (Optional). The conclusion section should
be included summarizing the outcome of the investigation in
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pubs.acs.org/acschas Commentary
case studies produced after a full investigation has been
completed. Some case reports, especially those related to
litigated matters, may contain expert opinions in the conclusion
section. Since opinions are the authors’, it should also be
recognized that other investigators looking at the same
information may produce different opinions. When opinions
are included, a statement regarding the degree of certainty
should be included. For example:
For this case study, the findings and opinions herein are
based on a review of relevant data, interview transcripts,
reports, documents available at this time, and referenced
scientific literature. All stated opinions are those of the
author(s) and held to a reasonable degree of scientific,
engineering, and technical certainty.
Recommendations (Optional). A list of recommenda-
tions may be included in case studies where there is a desire to
affect change in current procedures and practices. Since case
reports usually pertain to the subject case, the relevance of
recommendations to other similarly situated operations is
limited. When including recommendations, one should clearly
state that the recommendations pertain to the subject case of
the report. Recommendations should not be represented as a
general instruction to change operational practices for other
similar operations without careful consideration. These
recommendations should be in list format so they may be
easily referenced.
Acknowledgments. Many case studies rely on informa-
tion and data provided by others involved in the investigation,
including investigators from government agencies, insurance
investigators, police reports, and witnesses. It is appropriate to
acknowledge the contributions of others.
References. This reference section should include a list of
citations which identify the sources for data and statements in
the report. The references should follow the format established
in the ACS Guide to Scholarly Communications.6
Notes. Any additional relevant notes which aid the reader
in studying the case should be placed here.
■ CONCLUSION
Case studies provide a valuable mechanism and format for
documenting and disseminating information on observations
and incidents in the chemistry enterprise. Case studies are
especially important when documenting incidents and
observations associated with chemical health and safety.
Since case studies are not the product of a formal research
project, the publication standards for these reports are distinct,
requiring their own unique publication style and format. While
there may be different approaches to documenting a case based
on the use and availability of information, this commentary
seeks to provide guidance for writing a typical chemistry-
related case study.
■ AUTHOR INFORMATION
Other Author
Michael G. Koehler − Professional Analysis and
Consulting, Inc., Lisle, Illinois; orcid.org/0000-0003-
4177-5083
Complete contact information is available at:
https://pubs.acs.org/10.1021/acs.chas.9b00023
Notes
The author declares no competing financial interest.
ACS Chem. Health Saf. 2020, 27, 3−7
ACS Chemical Health & Safety

■
pubs.acs.org/acschas Commentary

REFERENCES
(1) Parkinson, J. An essay on the shaking palsy. In Whittingham and
Rowland for Sherwood; Needy and Jones: London, 1817.
(2) Gottlieb, M. S.; Schanker, H. M.; Fan, P. T.; Saxon, A.;
Weisman, J. D. Morbidity and Mortality Weekly Report 1981, 30 (21),
1−3.
(3) Miranda v. Arizona, 384 U.S. 436 (1966).
(4) Example: Case Study: Key Lessons for Preventing Inadvertent
Mixing During Chemical Unloading Operations, Chemical Reaction
and Release in Atchison, Kansas; Case Study No. 2017-01-I-KS; U.S.
Chemical Safety and Hazard Investigation Board, December 2019.
(5) National Center for Case Study Teaching in Science, University
of Buffalo. http://sciencecases.lib.buffalo.edu/cs/ (accessed Decem-
ber 10, 2019).
(6) Banik, G. M.; Baysinger, G.; Kamat, P. V.; Pienta, N. J. ACS
Guide to Scholarly Communications, 2020. https://pubs.acs.org/doi/
book/10.1021/acsguide (accessed December 10, 2019).
(7) Case Study: Texas Tech University Laboratory Explosion; Case
Study No. 201-05-I-TX; U.S. Chemical Safety and Hazard
Investigation Board, October 19, 2019.
(8) Laboratory Chemical Safety Summary (LCSS) Chem. Pub Docs,
National Institute of Health. https://pubchemdocs.ncbi.nlm.nih.gov/
lcss (accessed December 10, 2019).

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