Autoclave (equipment for sterilizing) was not tested with a biological indicator each day the sterilizer was used, Clinic could not provide records of testing of autoclave machine or servicing as per best practices.
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
Infection prevention and control concerns was identified through disease surveillance.
This infection prevention and control lapse involved a member of the regulatory college.
An initial onsite investigation was conducted on July 6, 2017.
|Single dose vials being used for multiple patients despite manufacturer recommendations that it is for single patient use only.||As per the product monograph, single dose vials to be used for single patient use only.||July 6, 2017|
|No documentation of staff competency involved in reprocessing medical devices.||Advised the operator to document evidence of education/training with regards to reprocessing medical devices.||Oct. 5, 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.||Oct. 5, 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.||Oct. 5, 2017|
|Only cold water, no hot water or alcohol based hand rub available at any of the handwashing basins or in the washrooms.||Provide alcohol based hand rub and both hot/cold running water at each handwashing sinks and in the washrooms.||Oct. 5, 2017|
|Chairs in the waiting room and in clinic rooms are to be smooth, non-porous, seamless and cleanable (e.g. no unfinished wood or cloth furnishings).||Surfaces and furnishings should be smooth, non-porous, seamless and cleanable.||Oct. 5, 2017|
|Sterility of Botox solution compromised due to removal of the rubber diaphragm/stopper.||Rubber stopper/diaphragm will remain in place and shall not be removed.||Oct. 5, 2017|
|Opened vials of medication were not labelled with date opened or expiration dates.||Vials are to be labelled with date opened and discarded at the appropriate time.||Aug. 31, 2017|
|Unopened vials and other products were not being discarded according to the manufacturer’s expiration dates.||Discard all expired vials and products.||Aug. 31, 2017|
|Needles in the clinic did not have safety engineered mechanisms.||Ensure safety engineered needles are used for procedures where appropriate.||Aug. 28, 2017|
|Infection prevention and control signage was not observed at the entrance of the clinic nor at the reception desk.||Ensure that infection prevention and control signage is provided at the entrance of the clinic and at the reception desk.||July 31, 2017|
|Absence of Material Safety Data Sheets (MSDS) for cleaning and disinfecting products.||MSDS for cleaning and disinfecting products must be available.||July 31, 2017|
|Screening process for potentially ill patients was not in place including lack of alcohol based hand rub (Alcohol Based Hand Rub) and availability of masks at the reception area||Ensure a screening process is in place for potentially ill patients upon arrival. Ensure to provide Alcohol Based Hand Rub and masks at the reception area.||July 31, 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.||July 27, 2017|
|Records were not kept to document that all sterilization parameters have been met or that the autoclave (equipment used for sterilizing) is serviced as per best practices.||Ensure that records are kept to document each sterilization cycle completed and servicing done the autoclave.||July 27, 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 Alcohol Based Hand Rub is provided for hand hygiene.||July 27, 2017|
|Medical instruments were loaded incorrectly when being processed in the autoclave.||Clinic was advised to use single use medical instruments until proper reprocessing practices are confirmed.||July 27, 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., clean covered containers).||July 27, 2017|
|Cleaning equipment used in reprocessing were not thoroughly cleaned and disinfected with a high-level disinfectant between uses or discarded.||Ensure that cleaning equipment used in reprocessing is being thoroughly cleaned and disinfected with a high-level disinfectant between uses or discarded.||July 27, 2017|
|Not all chemical products used for environmental cleaning had a drug identification number (DIN) from Health Canada.||Ensure all chemical products used for environmental cleaning have a DIN.||July 27, 2017|
|No eye wash station in vicinity of reprocessing area.||Operator to obtain an eye wash station and install it in the vicinity of the reprocessing area.||July 27, 2017|
|Non-critical medical equipment not disinfected between patients (such as blood pressure cuff).||Ensure that all non-critical medical equipment is disinfected between patients.||July 7, 2017|
|PPE such as gowns, gloves, masks, and eye protection are not being worn when reprocessing, handling blood or other body fluids or at point of care.||Appropriate PPE to be worn as per best practices.||July 7, 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.