The National Dental Centre Singapore (NDCS) has disciplined four staff members – including supervisors and senior management – for hygiene lapses, which led to the use of dental instruments that had not been fully sterilised.

The punishments included warnings and financial penalties, although specifics were not provided by SingHealth, which overlooks the NCDS.

Terming the lapse as "human error", it said yesterday that the four had been found to have "fallen short in their level of vigilance and speed in escalation of incident management."

SingHealth affirmed that measures have been put in place to improve the processes and culture at the NDCS to prevent a recurrence.

"We apologise for the lapses, and have started on corrective actions for improvement," it said.

Last month, on 12 June, the centre said that 72 packs of instruments, which had not been fully sterilised had been used to treat patients on 5 and 6 June.

NDCS said that it has been in touch with all, but four of the 714 patients who may have been treated with the equipment, and is also doing free blood test for those who have requested it. These tests check for the human immunodeficiency virus and hepatitis B and C.

A case of human error and fear of incident escalation

An investigation carried out by the SingHealth Risk Oversight Committee found that one staff member in the Central Sterile Supplies Department (CSSD) did not complete the final step of steam sterilisation for one batch of instruments in the late afternoon of 5 June. These instruments were then dispatched to outpatient clinics in level 2, 4 and 6 of NDCS.

Another staff member discovered the error and bean recalling the affected instruments after the supervisor was informed but failed to recover all of the instruments in the same day. The manager of the CSSD was not informed, SingHealth noted.

The next morning, before clinic operations began at 8am, the manager of the CSSD became aware of the incident when she noticed the sterilisation records of one batch of instruments from the previous day were incomplete.

At 4pm the same day, the issue escalated to the senior management of NDCS where the director of the NDCS immediately activated another round of recalls on 6 June, effectively recovering all the instruments.

MOH may consider regulatory action after investigation

SingHealth attributed the initial lapse to human error, adding that procedural weaknesses and a lack of vigilance contributed to the failure to deal with the incident quickly.

For instance, staff who were aware of the error failed to properly assess its potential impact. Instrument packs also have indicator strips which change colour when the sterilisation process is complete, but staff did not notice that these strips did not change colour.

"This reflects gaps in the level of vigilance on infection control and patient safety, and, in this particular context, instrument sterility," said SingHealth.

"Specific measures have been taken to improve the competency of staff involved in the sterilisation and handling of instruments."

The Ministry of Health said that the findings of the investigation will be reviewed, and together with its own investigation and assessment, consider if regulatory action is needed.

"The incident is a timely reminder for all public healthcare institutions of the need to be vigilant in delivering patient care safely, and to have a strong reporting and incident escalation culture," a MOH spokesperson said.

"The learning points from this incident will be shared across the healthcare system, so that we can collectively attain a high standard of patient safety and care." MIMS

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