Several incorrect infection prevention and control practices were identified. Multiple issues were observed with regards to lack of documentation, improper use of the autoclave (sterilizes equipment) and storage of sterile and disinfected equipment.
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 June 8, 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 June 9, 2017.
|Written policies and procedures were not available for infection prevention and control practices.||Ensure that written comprehensive policies and procedures related to infection prevention and control are based on the most current best practices available are reviewed and updated on a regular basis.||Aug. 16, 2017|
|Records were not kept to document that all high level disinfectant parameters had been met, including the equipment re-processed in the disinfectant.||Ensure that records are kept to document the use of high level disinfectants as per manufacturer’s instructions, as well as documentation of the staff member responsible for re-processing.||Aug. 10, 2017|
|Chemical products used for cleaning and disinfecting must be labeled and used according to Material Safety Data Sheets (MSDS) and manufacturer’s instructions, including verifying effectiveness of the product using test strips.||Ensure to label all chemical products, obtain test strips for high level disinfectants to verify effectiveness of the product daily and provide MSDS sheets for all chemical products on-site.||Aug. 10, 2017|
|Personal Protective Equipment (PPE) was not available at point of care or in the re-processing area (i.e., gowns, eye protection). PPE, such as masks and gloves, were not worn as per best practices.||Ensure that PPE is available at point of care and in the re-processing area. Ensure that PPE is worn as per best practices.||Aug. 10, 2017|
|There was no written schedule for regular environmental cleaning in the clinic.||Ensure to provide a regular schedule for environmental cleaning for all areas of the clinic that includes written procedures and clearly defined responsibilities.||Aug. 10, 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.||July 14, 2017|
|There was no evidence of on-going preventative maintenance for the ultrasonic washer.||Ensure ultrasonic washer receives recorded preventative maintenance.||July 14, 2017|
|There was no eye-wash station available for use in the re-processing area.||Ensure an eye-wash station is installed in the re-processing area.||July 14, 2017|
|Education and training related to infection prevention and control and re-processing of medical equipment/devices/instruments were not reported and documented.||Ensure that all education and training related to infection prevention and control and re-processing are reported, documented, and maintained on a regular basis. Ensure staff assigned to re-processing complete appropriate training. The Public Health Ontario online modules “Reprocessing in Community Health Care Settings” are recommended.||July 14, 2017|
|Screening process for potentially ill patients was not in place including lack of alcohol based hand rub (ABHR) and availability of masks at the reception area.||Ensure a screening process is in place for potentially ill patients upon arrival. Ensure to provide ABHR and masks at the reception area.||July 14, 2017|
|Packaged, sterilized instruments were not stored securely in a manner that prevents contamination.||Ensure that all instruments are packaged and stored in a manner that prevents contamination after sterilization process (i.e., keep cabinets storing instruments closed during procedures).||June 16, 2017|
|Sterilizer was not tested with a biological indicator each day the sterilizer was used. Biological indicator not available on-site.||Ensure that a biological indicator is obtained and used to test the sterilizer on a daily basis.||June 15, 2017|
|Items were not packaged according to the manufacturer's instructions.||Ensure that equipment loaded into sterilization packages are not touching in the package and package is placed in the unit according to manufacturer’s instructions.||June 15, 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.||June 15, 2017|
|The integrity of the stored sterilized packages displayed evidence of contamination (i.e., Watermarks).||Ensure that the integrity of the package is inspected after sterilization.||June 15, 2017|
|Medical equipment was not rinsed and dried (i.e., with lint-free cloth) prior to re-processing.||Ensure that equipment/devices are rinsed appropriately (as per manufacturer’s instructions for the high level disinfectant used) and air dried, or dried, with a clean lint-free cloth prior to re-processing.||June 15, 2017|
|Cleaning equipment (i.e., brushes) used in reprocessing was not thoroughly cleaned and disinfected with a high-level disinfectant between uses.||Ensure that cleaning equipment (i.e., brushes) used in reprocessing is being thoroughly cleaned and disinfected with a high-level disinfectant between uses.||June 15, 2017|
|Re-processing area did not meet best practices for work flow and storage to prevent cross-contamination including a dedicated hand hygiene sink.||Ensure that the re-processing area meets best practices for work flow and storage (i.e., dirty to clean). Ensure a sink is dedicated for hand hygiene only.||June 15, 2017|
|Appropriate infection prevention and control signage was not available at the entrance of the clinic and at the reception desk.||Ensure that signage regarding infection prevention and control is posted at the clinic entrance or at the reception desk.||June 15, 2017|
|Refrigerator on-site used for storage of products used for dental procedures also stored food products.||Ensure to designate a refrigerator on-site solely for products used for dental procedures.||June 15, 2017|
|An open vial of anesthetic was observed in a pre-loaded auto-injector in the re-processing area.||Ensure that all opened vials are discarded after use.||June 15, 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 at every point of use area.||June 15, 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.