Sterilization Issues at the National Dental Centre
What Went Wrong?
Launched in 1997, the National Dental Centre Singapore is one part of the SingHealth public healthcare network. The dental center is the central referral hub for all patients in Singapore needing specialist oral healthcare.
The Centre has aimed to be a leader in quality oral health care and seeks to deliver quality care to all patients. With comprehensive, unified clinical procedures, innovative and ongoing training, it works to provide unique environments for dental professionals and patients alike.
June 5th, 2017
The National Dental Centre became aware that a large number of instrument packs had been dispersed throughout the Centre for use without going through the third stage of the sterilization process.
The instruments had successfully been through the first two out of the three standard steps, which involve washing and thermal disinfection. Only the final step of steam sterilization had not been completed.
The lapse was first discovered on June 5th, and immediate efforts were made to recall all of the packs. The same day it was discovered that 72 of the packs had already been used on patients.
The NDCS released a statement regarding the sterilization process and the effects of the first two stages, relating that those two steps alone remove close to 100% of organisms. They also stated that the risk of infection would be extremely low.
Immediate action was taken to reach out to all patients and reassure them, then work with them to address any issues or concerns the patients may have.
June 6th, 2017
NDCS released the information that the rest of the instrument packs in question were found. The National Dental Centre Singapore worked to make contact with all patients who may have received treatment with the partially sterilized instruments, many of whom have returned to the Centre for additional clarification.
June 9th, 2017
The Ministry of Health (MOH) was officially informed of the lapse in procedure on June 9th. It was reported that the MOH directed both SingHealth and the NDCS to thoroughly review the incident and detail their findings and follow up actions to the MOH.
Since then the NDCS has conducted their review of the incident and has implemented additional controls to prevent future occurrences. The investigation was administered by the SingHealth Risk Oversight Committee.
June 13th, 2017
The NDCS reports it is working to contact the 714 patients who were treated on the Monday of the incident and the following Tuesday as a precaution.
June 20th, 2017
After working to contact 714 patients, the NDCS reported successful contact of 697 of the 714 patients. So far, 115 of the patients contacted returned to the facility for further clarification.
Subsequent efforts that are a result of these proceedings include the NDCS providing free blood tests for 92 patients who have requested them.
The tests will look for HIV and Hepatitis B, and C. Additional test will be provided in September and December to ensure they were not infected during their care at the dental center.
June 20, 2017
It was reported that four staff members of the NDCS, including members of senior management, have been punished as a result of the investigation’s findings. The disciplinary action taken has included warnings as well as financial penalties.
The results of this incident and its investigation have led to the improvement of the processes to prevent a relapse
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