SINGAPORE: Disciplinary action has been taken against four National Dental Centre Singapore (NDCS) staff members who were found to be directly involved in a hygiene lapse earlier this month, SingHealth said in a statement on Friday (Jun 30).
The staff members include supervisors and senior management who were "found to have fallen short in their level of vigilance, and speed in escalation of incident management," SingHealth said, adding that the disciplinary action include warnings and financial penalties.
In the incident earlier this month, 72 packs of dental instruments were found not to have been fully sterilised before they were used on patients. The instruments had undergone thermal washer disinfection but not the final step of steam sterilisation, and were used for patient treatment on Jun 5 and 6.
A committee was launched to investigate the incident, and the probe identified human error as the cause, SingHealth said.
"In addition, procedural weaknesses and a lack of vigilance of some staff involved had led to delays in escalation in incident management. The Committee has instituted measures to improve NDCS’ systems, processes and culture to prevent a recurrence," the statement said.
Specific measures have been taken to improve the competency of staff members involved in the sterilisation and handling of instruments, SingHealth said, adding that a report of the findings and follow-up action was submitted to the Ministry of Health (MOH) on Friday.
NATIONAL DENTAL CENTRE LAPSE: A TIMELINE
On Jun 5, an NDCS staff member of the Central Sterile Supplies Department (CSSD) did not adhere to the established protocol to complete the final step of steam sterilisation of one batch of dental instruments
The affected batch of instruments was sent to outpatient clinics on levels 2, 4 and 6 of NDCS in the late afternoon the same day. The error was discovered by another NDCS staff member at about that time.
Staff members started recalling the affected instruments after the supervisor was informed, but not all the affected instruments were retrieved. The manager of the CSSD was not informed, SingHealth noted.
The next day, before the start of clinic operations at 8am, the manager of the CSSD became aware of the incident when she noticed that the sterilisation records of one batch of instruments from the previous day was incomplete. Another recall of the affected instruments was initiated.
At 4pm that day, the issue was escalated to the senior management of NDCS. The director of the NDCS immediately activated another round of recalls to ensure that all affected instruments were retrieved, SingHealth said.
Before the clinic opened on Jun 7, all dental instruments were thoroughly checked and confirmed to have undergone the complete sterilisation process.
It was then assessed that, among the 714 patients who had visited the outpatient clinics, up to 72 of them could have come in contact with the affected instruments.
NDCS began contacting the patients on Jun 10 to inform them of the incident and reassure them of the "extremely low risk of infection", SingHealth said.
MEASURES TO STRENGTHEN PROCESSES
Following the incident, NDCS implemented additional controls to ensure the completeness of the sterilisation process, so as to prevent any recurrence. Clear instructions were disseminated to remind all staff to check the sterility of all dental instruments prior to use.
NDCS has also carried an audit of all the sterilisation records in the six months prior to the incident. The checks confirmed that sterilisation was documented to be completed in all other cases.
The SingHealth committee set out a series of measures to be implemented at NDCS. They include enhancing the standard operating procedures for the sterilisation and use of dental instruments; refining the accounting process for the sterilisation of the instruments; and strengthening the incident reporting and risk management frameworks.
The committee was also tasked to review the existing incident escalation policy and provide guidance on when to trigger immediate escalation.
Chairman of SingHealth Peter Seah, said that patient safety was its "first priority".
"We will ensure implementation of the corrective actions to prevent recurrence and work harder on strengthening a cluster-wide culture that places infection control and patient safety at the forefront of everything we do," he said.
HEALTH MINISTRY TO STUDY INCIDENT REPORT
The Health Ministry confirmed that it had received the NDCS incident report from SingHealth and that it was studying the observations and recommendations carefully.
"MOH will review the findings of the SingHealth investigation, and together with our own investigation and assessments, consider if regulatory actions are necessary," a spokesperson said.
"This 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.
"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."