Dr. T. Bak Dentistry


Summary

Sterile items were not stored in their sterile packaging until time of use. Medical equipment/devices were not dried prior to sterilization (e.g. with lint-free cloth).

Diseases resulting from similar errors in infection control may include:

  • Serious blood-borne infections (Hep B, Hep C, HIV, sepsis, meningitis/nervous system)
  • Respiratory infections
  • Stomach and intestinal infections
  • Skin infections

Contact

Public Health Nurse
Public Health Nurse
905-980-6000 ext. 7330, toll free 1-888-505-6074
id@niagararegion.ca


Findings and Corrective Measures

A complaint was identified from a member of the public on May 11, 2017, related to infection prevention and control concerns.

This infection prevention and control lapse involved a member of the regulatory college.

An initial onsite investigation was conducted on May 15, 2017.

Corrected Issues

IssueCorrectionDate Corrected
Education and training related to infection and prevention and control were not reported and documented. Ensure that all education and training related to infection and prevention and control are reported, documented, and maintained on a regular basis.June 30, 2017
Ultrasonic washer was not tested for efficacy at least weekly or according to manufacturer's recommendations.Ensure that the ultrasonic washer is tested at least weekly. June 2, 2017
Sharps containers were not available at point of use for direct disposal, to minimize handling or transportation of used sharps.Ensure that a sharps container is easily accessible in every point of use area.June 2, 2017
Written policy and procedures were not available for infection prevention and control practices.Ensure that policy and procedures related to infection prevention and control are available, reviewed and updated on a regular basis. June 2, 2017
Items were not packaged according to the manufacturer's instructions.Ensure that equipment loaded into sterilization packages are loaded without overlapping or touching in the packaging.May 19, 2017
Upon opening the reprocessed medical equipment, the integrity of the packaging and the equipment was not checked.Ensure that the integrity of the package is inspected after sterilization.May 19, 2017
Medical equipment were not dried prior to sterilization (e.g. with lint-free cloth).Ensure that equipment/devices are air dried or dried with a clean lint-free cloth prior to sterilization. May 19, 2017
Sterile items were not stored in their sterile packaging until time of use.Ensure that sterile items are stored in their packages until time of use.May 19, 2017
Packaged, sterilized instruments were not stored securely in a manner that prevents contamination.Ensure that sterilized instruments are stored in a manner that prevents contamination (i.e. keep cabinets storing instruments closed during procedures).May 19, 2017
Sterilizer was not tested with a biological indicator each day the sterilizer was used.Ensure that the biological indicator is tested on a daily basis. May 19, 2017
Cleaning equipment used in reprocessing was not thoroughly cleaned and disinfected with a high-level disinfectant between uses.Ensure that cleaning equipment used in reprocessing is being thoroughly cleaned and disinfected with a high-level disinfectant between uses.May 19, 2017
There was no dedicated hand hygiene sink and/or alcohol based hand rub in the reprocessing area. Ensure that either a dedicated hand hygiene sink and/or alcohol based hand rub is provided in the reprocessing area. May 19, 2017
Records were not kept to document that all sterilization parameters have been met.Ensure that records are kept to document each sterilization cycle completed. May 19, 2017
Personal protective equipment (such as masks) were not worn appropriately.Ensure that masks are not hung around the neck outside the patient rooms.May 19, 2017
Effective hand hygiene requirements were not in place: no artificial nails or nail enhancements and preferably no polish.Ensure that all staff following the best practice related to hand hygiene of nails. May 19, 2017
Appropriate infection prevention and control signage was not available at the entrance of the clinic and at the reception desk.Ensure that signage provided by Public Health is posted at the clinic entrance or at the reception desk. May 19, 2017
There were no tissue boxes available in the reception/waiting area.Ensure that tissue boxes are available in the reception/waiting area.May 17, 2017

Health Risks and Inspections

In the event that a direct health risk is identified for clients who visited this establishment, Niagara Region Public Health will contact those at risk with advice around any medical follow-up.

For general updates regarding this investigation, continue to monitor this website.


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