Hygiene Lapse - Another lapse within Singhealth Group
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.
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.
What can we learn from the Incident?
Having a quality system does not necessarily ensure quality work is delivered all the time. It requires much dedication with check and balance from all users of the instruments and equipment. This does not restrict to the staff of the sterile and supply department who did the sterilization of the instrument but to clinic staff and dental surgeon who perform dental treatment and surgery on patients. There must be a host of checklist to ensure there isn't anything that could have missed out. Over time, there must be a stricter review and improvement over the present protocol to ensure you are not overly contented or overlooked with certain necessary implementation.
Hepatitis C Outbreak Incident
An earlier incident in SGH.
Poor infection prevention and control measures at the Singapore General Hospital (SGH) were the main cause of the hepatitis C outbreak there earlier this year, the Independent Review Committee (IRC) that was tasked to look into has concluded.
The Independent Review Committee was tasked to look into the spread of the virus in SGH's wards 64A and 67 that affected 25 patients. Of the 25 affected transplant and renal patients, eight have died. The committee said the hepatitis C infection was a "likely contributory factor to the death of seven cases".
All the patients in the affected wards had many exposures to intravenous medication or laboratory tests that required blood taking, which increased their risk of getting hepatitis C, which is a blood-borne virus.
The report highlighted lapses in SGH's practices, including poor infection control and delay in escalating the incident to SingHealth and MOH. Among other things, the committee noted that the SGH renal team sensed that something was amiss when 4 cases were detected in mid-May, it did not recognize this as an outbreak due to unusual nature and thus it did not report to the Infection Control immediately.
12 staff in leadership positions, Singapore General Hospital says disciplinary sanctions meted out include stern warnings and financial penalties for gaps in their roles in managing the outbreak or in infection control. Four Ministry of Health (MOH) senior officers were also disciplined.
MOH said in a separate press release that four MOH officers holding director-level or equivalent roles were also disciplined for "their failure to intervene early and to ensure the infectious disease notification and reporting system was effective and rigorous".
"The disciplinary actions were decided on based on the specific roles, responsibilities and job nature of the officers, as well as the nature of the incident and the impact of their actions in this episode.
"Mitigating and aggravating factors were also taken into consideration, to ensure a comprehensive and fair assessment of the situation. Those with higher level of responsibilities have received heavier penalties."
Reference: the article was reported in Channel Newsasia and StraitsTimes in Singapore in Dec 2015, Mar 2016, 1 Jul 2017, etc.
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