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Tan Tock Seng Hospital puts patients at risk of infection by failing to properly sterilise dental instruments

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Tan Tock Seng Hospital (TTSH) has revealed that patients at its dental clinic may be at risk of infections after it found that 8 packs of dental instruments that were used for treatments between 28 Nov and 8 Dec this year had not been fully sterilised.

TTSH said in a press release yesterday 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 hospital was alerted to the lapse when a staff member found that the last of three sterilisation steps (or Step 3 of the following TTSH sterilisation process) was not completed before the affected instruments were used, on 4 Dec.

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TTSH reported that eight packs of instruments that were processed on 28 November were discovered to have not completed the last step of the sterilisation process, on 5 December, and had been used for patient treatment at the TTSH Dental Clinic.

Despite this, TTSH assures that the “risk of infection to patients arising from this incident is assessed to be extremely low given that the completion of the earlier steps in the sterilisation process would have removed close to 100% of organisms of concern.”

In spite of this assurance, the hospital is presently calling “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.”

TTSH’s Medical Board Chairman, Associate Professor Thomas Lew, apologised for the lapse and promised to improve their vigilance:

“We sincerely apologise to our patients and their families for the lapse and distress caused. We are contacting the patients who received treatment during the affected period. Additional measures are in place to bolster and improve our vigilance and workflows to ensure the wellbeing and safety of all our patients.”

This is not the first time dental patients in Singapore have been exposed to the risk of infections due to sterilisation lapses.

Last year, it was discovered that 72 packs of dental instruments, that were used to treat patients between 5 and 6 June 2017 at the National Dental Centre Singapore, were not completely sterilised.

Health Minister Gan Kim Yong has since expressed his disappointment at the re-occurence of such a lapse. Speaking to the press, he said that the Ministry of Health (MOH) takes a serious view of this latest incident and will “study” it closely:

“We take a serious view of the incident at TTSH Dental Clinic and I am disappointed it has happened despite our efforts. 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.
“This incident is a timely reminder to all healthcare institutions to maintain a high level of vigilance in delivering patient care safely at all times.”

MOH has reportedly ordered TTSH to conduct thorough reviews of the incident and report the findings before taking necessary action.

Interestingly, TTSH noted the 2017 National Dental Centre incident in its press release as it said that it had learned from the previous incident and actually had implemented “several improvement measures” to its processes over the past year.

It admitted that this latest “incident shows however that further improvements are necessary.” TTSH revealed that it has since suspended elective procedures at the Dental Clinic until tomorrow to allow a safety time-out:

“Learning from a previous incident at the National Dental Centre Singapore (NDCS) in June 2017, the TTSH Dental Clinic had put in place several improvement measures over the past year. These include revising pouching and documentation procedures, partitioning functional work areas, and instituting that completion of the sterilisation process be verified by two staff. TTSH Dental Clinic staff were also required to undergo a new competency assessment, and sent for training and certification at TTSH’s central sterile supply department (CSSD).
“In December 2017, the Ministry of Health had conducted an inspection of TTSH’s CSSD. The TTSH Dental Clinic also underwent biannual audits on their sterilisation procedures in May 2017, November 2017, May 2018 and October 2018. There were no procedural or equipment gaps found during these audits. In addition, the TTSH Dental Clinic underwent an inspection by the Joint Commission International (JCI), which found its processes to be in conformance with standards.
“This incident shows however that further improvements are necessary. TTSH and the National Healthcare Group are conducting thorough reviews. As a precautionary measure, elective procedures at the Dental Clinic have been suspended since 8 December to allow a safety time-out. Meanwhile 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. Elective outpatient dental services will resume from 12 December.”
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