18 Tan Tock Seng Hospital staff to be disciplined after safety lapse at dental clinic
Dental instruments were found not to have completed sterilisation process before being reused
Following an investigation into an incident last year, 18 staff from a dental clinic at Tan Tock Seng Hospital (TTSH) face disciplinary action, including financial penalties and warnings.
In November, equipment that had not gone through the final sterilisation process was used on patients at TTSH's Dental Clinic.
The investigation revealed that the staff did not adhere to the expected requirements of quality and safe care of patients.
The group, which includes senior management and supervisors, will also undergo appropriate training.
The National Healthcare Group (NHG) released a statement yesterday concluding that the incident was caused by human error.
Eight packs of instruments were found not to have completed the final step of sterilisation and were used for patient treatment between Nov 28 and Dec 5.
While the NHG said the risk of infection to patients due to the error was extremely low given the completion of the earlier steps in the sterilisation process, it contacted all 575 patients who had been treated at the dental clinic during the affected period to provide support and address concerns.
The investigation carried out by the NHG review committee, and included experts from other health clusters, found that on Nov 28, a staff member from the TTSH Dental Clinic failed to follow protocol and loaded packs of instruments into the autoclave machine without initiating the steam sterilisation cycle.
Another staff member then unloaded and stored the packs, not realising they had not undergone the final step of sterilisation.
The packs were also not verified for sterility before use.
The committee also found that incident reporting could be improved as a faster response could have significantly reduced the impact of the error.
After the incident came to light, elective procedures at the clinic were suspended for a safety time-out and all dental instruments were thoroughly checked and confirmed to have undergone the complete sterilisation process.
Additional control measures were also implemented to prevent a repeat incident, including strengthening the on-site sterilisation process and optimising the workflow to reduce the probability of human error.
An oversight committee has been appointed by the chairman of the NHG Clinical Board to oversee the implementation of the recommendations by the review committee.
Health Minister Gan Kim Yong expressed his disappointment when the incident first came to light in December, after steps had been taken "to minimise the risk of a breach in patient safety" following an earlier incident at the National Dental Centre Singapore in 2017, when 72 packs of instruments were found not to have been sterilised completely.
Yesterday, Professor Philip Choo, group chief executive officer of NHG, said: "On behalf of NHG, we sincerely apologise for the incident.
"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."
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