18 staff members taken to task at TTSH dental clinic over equipment hygiene lapse
Disciplinary actions will include warnings and financial penalties, while appropriate retraining and education will also be undertaken by staff members.
SINGAPORE — Eighteen staff members at Tan Tock Seng Hospital’s (TTSH) dental clinic will be counselled and disciplined following an incident last year, where eight packs of dental equipment did not undergo the final step of sterilisation and were used for treatment between Nov 28 and Dec 5.
The disciplinary actions against the employees — among them senior management members and supervisors — will include warnings and financial penalties. They will also need to go through retraining and education.
In a statement on Tuesday (Jan 8), the National Healthcare Group (NHG) said that its review committee, which was established following the incident, has completed its independent investigation and identified the main cause as “human error with a lapse in adherence to the established sterilisation process and verification protocol".
Weak sterilisation protocols and work instructions were also found to be contributing factors. There were gaps, too, in the level of vigilance, with staff failing to verify the sterility of the instruments before use.
The committee flagged the lack of timeliness in the reporting of the incident as well. “Earlier escalation and faster response could significantly reduce the impact of the incident,” the statement added.
The committee was chaired by the chief executive officer of the Institute of Mental Health, Professor Chua Hong Choon, as well as experts from other health clusters.
It submitted its full investigation report with follow-up actions to the Ministry of Health (MOH) on Tuesday.
Said NHG group chief executive officer Philip Choo: “On behalf of NHG, we sincerely apologise for the incident. I would like to thank the Committee for its work in reviewing the incident and the recommendations put forth to improve our systems and processes.”
He added: “Patient safety will continue to be our utmost priority, and we hold our staff to the highest standards of quality and safe care of patients. We will work harder to ensure that the well-being and safety of our patients are best served in all our institutions.”
MOH’S STATEMENT
In a separate statement, MOH said that it has received the investigation reports from NHG and TTSH, and will review them along with the ministry's own investigation and assessments. The ministry said it will consider whether regulatory and other actions are necessary.
MOH stressed that patient safety is "paramount". Following the lapse, it has "instructed all public and private healthcare institutions to further strengthen their systems and ensure staff awareness and strict adherence to all processes for patient safety and care".
MOH said it will also consult relevant technical experts, and consider further actions to be taken to reduce the risks of a re-occurrence. It plans on sharing learning points across the healthcare system to improve patient safety.
"This incident is a timely reminder for all healthcare institutions of the need to maintain a high level of vigilance in delivering patient care safely, and to have a strong reporting and incident escalation culture," said an MOH spokesman.
WHAT HAPPENED LAST YEAR
On Dec 4, a staff member from TTSH’s dental clinic found a dental instrument had not gone through the final step of steam sterilisation.
A physical check of all dental instruments was then initiated, and by Dec 7, it was confirmed that eight packs of dental instruments were not thoroughly sterilised on Nov 28.
Investigations showed that on Nov 28, a staff from the clinic failed to follow established protocol and loaded packs of instruments into the autoclave machine without initiating the steam sterilisation cycle, which is the last stage of sterilisation.
Another staff subsequently unloaded and stored the packs, without realising that the packs had not undergone the final step of sterilisation. These packs were not verified for sterility before use.
TTSH then began contacting all 575 patients who were treated at the clinic during the affected period to inform them of the incident and reassure them of the extremely low risk of infection.
Elective procedures at the clinic were suspended for a safety time-out from Dec 8 to 12. During this period, all dental instruments were thoroughly checked and confirmed to have undergone the complete sterilisation process.
Additional control measures were implemented to ensure that the sterilisation process was conducted in accordance with established processes and that the verification protocol was strictly adhered to.
