Cause of Lapse in Use of Partially Sterilised Instruments at National Dental Centre in June 2017

The lapse was caused by human error when a staff member failed to complete all sterilisation steps, compounded by supervisors not recognising the error promptly, leading to delayed escalation and potential use of up to 72 packs of affected instruments.
Procedural weaknesses were identified across the instrument issuance, receipt, and unpacking processes, with a lack of vigilance and failure to detect the error before use on patients.
Immediate measures included additional independent verification of sterilisation, clearer work instructions for staff, and plans to strengthen standard operating procedures, documentation, incident escalation, and training.
The healthcare institution committed to sharing lessons learned across clusters to improve patient safety and care standards collectively.

Full Transcript

Dennis Tan Lip Fong

Mr Dennis Tan Lip Fong asked the Minister for Health (a) what is the cause of the lapse leading to use of the partially sterilised instruments on patients at the National Dental Centre (NDC) in June 2017; (b) what are the procedural weaknesses in the NDC's process for ensuring that instruments are fully sterilised before use; and (c) what measures have been taken to ensure that similar lapses do not occur again.

Gan Kim Yong

Patient safety is of utmost importance to our public healthcare institutions. We apologise for the lapse at the National Dental Centre Singapore (NDCS) on 5 June and 6 June, which had led to the use of partially sterilised dental instruments.

SingHealth has conducted an investigation and the Ministry of Health has received its report on 30 June 2017. The Ministry is reviewing the report and is also conducting its own investigation.

The SingHealth investigation showed that the incident originated from human error by a staff, who failed to complete all the steps in the sterilisation process for one batch of dental instruments. In addition, her supervisor and department manager did not fully recognise the potential impact of the error. As a result, there was a delay in escalating the incident to senior management, and up to 72 packs of affected instruments might have been used on patients, before all affected instruments were successfully recalled.

The findings also revealed procedural weaknesses and a lack of vigilance amongst some staff. At various points of the process – from the issuance of the instruments from the Central Sterile Supplies Department (CSSD), through the receipt of the instruments at the clinics, to the unpacking of the instruments before use on patients, the error could have been detected and an alert raised.

Following the incident, NDCS has instituted immediate corrective measures. Additional independent verifications have been put in place to ensure completeness of the sterilisation process. Clearer work instructions have been disseminated to all staff to ensure that the sterility of the dental instruments is checked prior to use.

NDCS will strengthen the following: (a) standard operating procedures for sterilisation, handover and use of dental instruments; (b) documentation and inventory accounting process for sterilisation and movement of dental instruments from CSSD to the clinics, and (c) incident escalation and reporting, recall and risk management frameworks.

In addition, NDCS will institute regular training and competency assessments for all staff involved in the sterilisation and handling of instruments to ensure familiarity with the processes.

While the risk of infection to affected patients is extremely low in this incident, it is a serious breach of the institution's infection control system nonetheless. Our healthcare institutions need to be more vigilant and have a stronger reporting and incident escalation culture. These will enable us to detect and mitigate any incidents expeditiously.

The learning points from this incident will be shared across the healthcare clusters, so that we can collectively improve our standard of patient safety and care.

Full Transcript

Dennis Tan Lip Fong

Gan Kim Yong

SingHealth has conducted an investigation and the Ministry of Health has received its report on 30 June 2017. The Ministry is reviewing the report and is also conducting its own investigation.

In addition, NDCS will institute regular training and competency assessments for all staff involved in the sterilisation and handling of instruments to ensure familiarity with the processes.

The learning points from this incident will be shared across the healthcare clusters, so that we can collectively improve our standard of patient safety and care.

The lapse was caused by human error when a staff member failed to complete all sterilisation steps, compounded by supervisors not recognising the error promptly, leading to delayed escalation and potential use of up to 72 packs of affected instruments.
Procedural weaknesses were identified across the instrument issuance, receipt, and unpacking processes, with a lack of vigilance and failure to detect the error before use on patients.
Immediate measures included additional independent verification of sterilisation, clearer work instructions for staff, and plans to strengthen standard operating procedures, documentation, incident escalation, and training.
The healthcare institution committed to sharing lessons learned across clusters to improve patient safety and care standards collectively.

Cause of Lapse in Use of Partially Sterilised Instruments at National Dental Centre in June 2017

Summary

Questions Identified

Full Transcript

Dennis Tan Lip Fong

Gan Kim Yong

Summary

Questions Identified

Cause of Lapse in Use of Partially Sterilised Instruments at National Dental Centre in June 2017

Summary

Questions Identified

Full Transcript

Dennis Tan Lip Fong

Gan Kim Yong

Summary

Questions Identified