A total of 16 senior staff have been disciplined for their role in the hepatitis C infections linked to eight deaths at Singapore General Hospital (SGH) last year and a national response team has been set up to deal with disease outbreaks in the future.
Responding to the outbreak that exposed gaps in the system, both SGH and the Ministry of Health (MOH) have acted to strengthen their processes while pulling up senior staff who were found wanting when the infections flared up last year.
Four senior MOH officials - holding director-level or equivalent roles - were punished, said the ministry yesterday, adding that "disciplinary sanctions include warnings, stern warnings and financial penalties".
They had failed to intervene early and to ensure that the disease notification system was effective. "Those with higher level of responsibilities have received heavier penalties," said an MOH spokesman.
At SGH, where 25 patients were infected - including 20 who had received kidney transplants and were more vulnerable - the sanctions cut wider.
"For 12 staff in leadership positions, including senior SGH management, the disciplinary sanctions meted out include stern warnings and financial penalties for gaps in their roles in managing the outbreak or in infection control," the hospital said.
Both MOH and SGH declined to name those who were disciplined.
SGH became aware of the outbreak in its renal ward in May last year, but it was September by the time it informed the ministry's director of medical services.
In December, an independent review committee set up by MOH ascribed the outbreak to "multiple overlapping factors, including gaps in infection control procedures and protocols".
It also pointed out that there was no designated division within MOH to deal with an unusual healthcare-associated infection like hepatitis C, which led to delays in recognising it. To plug these gaps, MOH has set up a National Outbreak Response Team from March 1, to help healthcare institutions deal with disease outbreaks.
The reporting procedures for infectious diseases will also be simplified. Doctors can call an MOH hotline directly to flag urgent cases.
Also, instead of making two reports, doctors need to notify the ministry just once, without waiting for laboratory confirmation. MOH will follow up with the laboratories on is own to match results.
SGH, too, has initiated a wide- ranging review of its systems.
Potentially contaminated surfaces are being regularly disinfected. There are enhanced training programmes in place for staff, whose practices are also being closely monitored. Needleless connectors are being used hospital-wide.
SGH has also engaged international consultants to review clinical processes at its renal unit.