18 Tan Tock Seng Hospital dental clinic staff penalised for incompletely sterilised instruments
Disciplinary action, including warnings and financial penalties, will be taken against 18 Tan Tock Seng Hospital (TTSH) staff members for safety lapses committed at the hospital’s dental clinic.
Between 28 November and 5 December last year, up to eight dental patients at TTSH may have been treated with instruments that did not complete the final step of sterilisation.
The staff, including senior management and supervisors, “have not adhered to the expected requirements of quality and safe care of patients”, said the National Healthcare Group (NHG) in a statement on Tuesday (8 January).
They will also be made to undergo appropriate retraining and education.
The NHG Review Committee – chaired by the CEO of the Institute of Mental Health (IMH), Professor Chua Hong Choon, and includes experts from other health clusters – submitted its full investigation report into the lapses with follow-up actions to the Ministry of Health (MOH) on Tuesday.
The committee identified “human error with a lapse in adherence to the established sterilisation process and verification protocol” as the main cause of the incident.
Enhancing sterilisation process
Investigations showed that a staff member at the TTSH dental clinic had loaded eight packs of instruments into the autoclave machine without initiating the steam sterilisation cycle, the final step of the sterilisation process, on 28 November last year.
Another staff later unloaded and stored the packs without realising that the packs had not
undergone steam sterilisation. They were not verified for sterility before use.
Each pack is typically used for one patient, while some patients may use more than one.
On 4 December, a TTSH dental clinic staff found a dental instrument that had not gone through steam sterilisation.
A physical check of all dental instruments was conducted the next day. By 7 December, the dental clinic confirmed that eight packs of instruments did not complete steam sterilisation and could have been used for patient treatment at the clinic between 28 November and 5 December.
On 9 December, the hospital began contacting all 575 patients who were treated at the clinic during the affected period to inform them of the incident.
TTSH then suspended elective procedures at the clinic for a safety time-out from 8 to 12 December. During this period, all dental instruments were thoroughly checked and confirmed to have undergone the complete sterilisation process.
Additional control measures were implemented to ensure that the sterilisation process was conducted in accordance with established processes and that the verification protocol was strictly adhered to. These include linking the steps of loading the autoclave machine and starting of the sterilisation cycle. The uploading of packs after the sterilisation cycle must only occur after the verification of sterilisation.
An oversight committee has been appointed by the Chairman of the NHG clinical board to oversee the implementation of the recommendations by the NHG Review Committee.
The findings and recommendations from the incident will be shared across all NHG institutions and external audits will be conducted to ensure that staff adhere fully to all processes.“On behalf of NHG, we sincerely apologise for the incident,” said Professor Philip Choo, group CEO of NHG. “Patient safety will continue to be our utmost priority, and we hold our staff to the highest standards of quality and safe care of patients. We will work harder to ensure that the well-being and safety of our patients are best served in all our institutions.”
The incident comes about 18 months after a similar one at National Dental Centre Singapore (NDCS), where up to 72 patients were treated with dental instruments which were not fully sterilised.
Following the NDCS incident, the Ministry of Health conducted audits of all licensed public and private healthcare institutions with central sterile supply departments (CSSDs) to assess their compliance with established sterilisation processes. The audits showed that all CSSDs were in compliance.
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