Dr. A.M. Holody Dentistry Professional Corporation


Summary

Issues were observed with regards to lack of infection prevention and control practices in the reprocessing area. Policies and Procedures were not current at time of investigation.

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
  • Skin / soft tissue 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 referral was made by on September 29, 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 October 2, 2017.

Ongoing Issues

IssueCorrectionLast Updated
Written policy and procedures were not fully available for infection prevention and control practices, and reprocessing.Ensure that policy and procedures related to infection prevention and control, and reprocessing are available, reviewed and updated on a regular basis.Oct. 5, 2017

Corrected Issues

IssueCorrectionDate Corrected
The integrity of the stored sterilized packages displayed evidence of contamination (i.e., condensation, piercing of packaging).Ensure that the integrity of the package is inspected after sterilization.Oct. 13, 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.Oct. 13, 2017
Dental instruments were not packaged according to the manufacturer’s instructions.Ensure dental instruments are packaged according to manufacturer’s instructions (i.e. instruments are in their open/unhinged positions, do not overlap and the appropriate pouch size is used.) Oct. 4, 2017
Reprocessing area did not meet best practices for work flow and storage to prevent cross-contamination.Ensure that the re-processing area meets best practices for work flow and storage (i.e., dirty to clean).Oct. 4, 2017
Medical equipment was not dried (i.e., with lint-free cloth) prior to re-processing.Ensure that dental tools are thoroughly dried prior to packaging.Oct. 4, 2017
Dental instruments which have been reprocessed cannot be differentiated from dental instruments which have not been reprocessed.Ensure that reprocessed dental instruments can be identified. Oct. 4, 2017
Sterilizer was not tested with a biological indicator each day the sterilizer was used.Ensure that a biological indicator is used to test the sterilizer on a daily basis.Oct. 3, 2017
Full records that document all sterilization parameters have not been met.Ensure that a detailed log is kept to verify and document that all physical parameters at the end of every load.Oct. 3, 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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