Diabetic Foot Clinic Fort Erie


Summary

Proper functioning of sterilizer was not verified using indicators (physical, chemical and biological). Chemical products used for disinfection/sterilization were used beyond their expiration date.

Diseases resulting from similar errors in infection control may include:

  • Serious blood-borne infections (Hep B, Hep C, HIV, sepsis, meningitis/nervous system)
  • 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 complaint was identified from a member of the public on October 25, 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 31, 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. Nov. 8, 2017

Corrected Issues

IssueCorrectionDate Corrected
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. Nov. 15, 2017
Proper functioning of sterilizer was not verified using indicators (physical, chemical and biological).Ensure that the sterilizer is tested with all required indicators when the sterilizer is used. Nov. 8, 2017
Medical equipment was not dried (i.e. with lint-free cloth) before re-processing.Ensure that foot care instruments are thoroughly dried before packaging.Nov. 8, 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 indicators (physical, chemical and biological) have passed during sterilization. Nov. 8, 2017
Instruments were not packaged according to the sterilizer manufacturer’s instructions.Ensure instruments are packaged according to sterilizer manufacturer’s instructions (i.e. instruments are in their open/unhinged positions, do not overlap and the appropriate pouch size is used). Nov. 8, 2017
Instruments which have been reprocessed cannot be differentiated from instruments which have not been reprocessed.Ensure that reprocessed instruments can be identified. Nov. 8, 2017
Appropriate infection prevention and control signs were not available at the entrance of the clinic nor the reception desk. Ensure that signage is posted at the clinic entrance or the reception desk. Nov. 8, 2017
No eyewash station in the vicinity of reprocessing area. Operator to obtain an eyewash station and install it in the vicinity of the reprocessing area. Nov. 7, 2017
No dedicated hand hygiene sink and/or alcohol-based hand rub in the reprocessing area. Ensure that a dedicated hand hygiene sink and/or alcohol-based hand rub is provided for the reprocessing area. Nov. 7, 2017
Chemical products used for disinfection/sterilization were used beyond their expiration date. Ensure to follow the manufacturer’s instructions; chemical products are not to be used beyond their expiration date. Nov. 7, 2017
The 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. Nov. 7, 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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