18 staff disciplined after “human error” at TTSH put patients at risk of infection

Tan Tock Seng Hospital (TTSH) has disciplined 18 staff after investigations by the National Health Group (NHG) found that “human error” caused the hospital to put patients at risk after staff failed to fully sterilise 8 packs of dental instruments that were used for treatments between 28 Nov and 8 Dec 2018.

TTSH has issued warnings and imposed financial penalties against the 18 staff for the lapse.

According to the NHG investigations, the staff at TTSH’s dental clinic loaded 8 packs of instruments in an autoclave machine used for steam sterilisation, but failed to start the process. Subsequently, another staff unloaded and stored the unsterilised instruments, unaware that the instruments had not undergone steam sterilisation.

Last month, TTSH had said that although 575 patients had been treated at the dental clinic during the affected period, only up to eight patients “may have received treatment using the affected instruments.”

The Ministry of Health (MOH) has, in the meantime, said that it is also investigating the case and that it will review the incident reports from NHG and TTSH to determine whether  further regulations or actions are needed.