Up to 8 patients treated with partly sterilised dental instruments at Tan Tock Seng Hospital
SINGAPORE: Eight packs of dental instruments from Tan Tock Seng Hospital (TTSH) that had not been fully sterilised may have been used for outpatient treatment at the hospital's dental clinic, said the Ministry of Health (MOH) in a news release on Monday (Dec 10).
According to the ministry, up to eight patients who visited the clinic between Nov 28 and Dec 5 may have been treated with the affected instruments.
However, the hospital assured patients in a news release on Monday that the risk of infection due to this incident is "extremely low".
THE STERILISATION PROCESS
According to the hospital, the sterilisation process involves three steps.
The first step involves manual washing and ultrasonic machine sonication. During the second step, the instruments are air dried, packed, sealed and labelled.
The final step, which was missed for the affected instruments, involves putting the sealed instruments through steam sterilisation to remove bacterial spores, said the hospital.
Tan Tock Seng said that "close to 100 per cent of organisms of concern would have been eradicated" by the second step.
"Nevertheless, we are contacting all 575 patients who had been treated at the dental clinic during the affected period to reassure them on their low risk of infection, provide support and address any concerns," said Tan Tock Seng.
"PATIENT SAFETY IS PARAMOUNT"
The incident was uncovered after a dental clinic staff from the hospital found a dental instrument last Tuesday that had not gone through the final step of steam sterilisation.
Following a check of all dental instruments the next day, it was found that eight packs of instruments that were processed on Nov 28 had not completed the last step of the sterilisation process and had been used for patient treatment at the Tan Tock Seng dental clinic.
“Patient safety is paramount," said Minister for Health Mr Gan Kim Yong after the incident.
MOH noted that a similar incident had taken place at the National Dental Centre Singapore (NDCS) in June 2017.
"We take a serious view of the incident at TTSH Dental Clinic and I am disappointed it has happened despite our efforts," Mr Gan said.
"This incident shows however that further improvements are necessary," added the hospital after noting that several "improvement measures" had been put in place following the NDCS incident and that the dental clinic had passed previous inspections and audits.
"We sincerely apologise to our patients and their families for the lapse and distress caused," said Associate Professor Thomas Lew, chairman medical board, TTSH.
Nonetheless, as a precautionary measure, the hospital added that elective procedures at the dental clinic have been suspended since Saturday to allow for a safety time-out.
"We have put in place added controls at the dental clinic, and reinforced efforts to heighten staff awareness and full adherence to our processes for patient safety and care across the entire hospital," it added.
Elective outpatient dental services will resume from Wednesday, it added.
HEALTH MINISTRY'S FOLLOW-UP
In light of the incident, MOH also said that it is rendering support to the hospital in the implementation of additional control measures and in reaching out to patients who may be affected.
"MOH has also directed the National Healthcare Group and TTSH to conduct thorough reviews of the incident, and report their findings and follow-up actions to MOH," said the ministry.
"MOH will study the incident closely, consult relevant technical experts, and consider further actions to be taken to reduce the risks of a re-occurrence across the healthcare sector," added Mr Gan.
The ministry has also asked the management of public healthcare institutions to review their processes in all areas where sterilisation is performed, as well as to ensure that staff are compliant with the processes.