Failure of sterilization in a dental outpatient facility: Investigation, risk assessment, and management

Abstract

In 2017, an incident of failed sterilization of dental instruments occurred at a large dental outpatient facility in Singapore. We aim to describe findings of the investigation of the sterilization breach incident, factors related to risk of viral transmission to the potentially affected patients, and the contact tracing process, patient management, and blood test results at a 6-month follow-up. A full assessment of the incident was immediately carried out. The factors related to risk of viral transmission due to affected instruments were analyzed using 3 keys points: breached step(s) and scale of the incident, prevalence of underlying bloodborne diseases and immunity in the Singapore population, health status of potential source patients, and type of dental procedure performed, and health status of affected patients and type of dental procedure received. Up to 72 affected instrument sets were used in 714 potentially affected patients who underwent noninvasive dental procedures. The investigation revealed that there was a lapse in the final step of steam sterilization, resulting in the use of incompletely sterilized items. The assessment determined that there was an extremely low risk of bloodborne virus transmission of diseases to the patients. At the 6-month follow-up, there were no infected/colonized cases found related to the incident. Lapses in the sterilization process for medical and dental instruments can happen, but a risk assessment approach is useful to manage similar incidents. Quick response and proper documentation of the sterilization process can prevent similar incidents.

Figure 1.

Components of Investigations.