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:
Public Health Nurse
Public Health Nurse
905-980-6000 ext. 7330, toll free 1-888-505-6074
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.
|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|
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.