Parliament: MOH instructed all healthcare institutions to conduct safety reviews after TTSH dental lapse

Up to eight packs of dental equipment had not been fully sterilised at Tan Tock Seng Hospital's Dental Clinic in November 2018.
Up to eight packs of dental equipment had not been fully sterilised at Tan Tock Seng Hospital's Dental Clinic in November 2018.PHOTO: ST FILE

SINGAPORE - The Ministry of Health (MOH) instructed all public and private healthcare institutions to "conduct immediate safety reviews" immediately after it discovered that some dental equipment which had not been fully sterilised was used at Tan Tock Seng Hospital (TTSH).

Dr Amy Khor, Senior Minister of State for Health, told Parliament on Monday (Jan 14) that the MOH has also required them to strengthen their sterilisation systems and to ensure staff compliance with the required processes.

She was replying to questions from Miss Cheng Li Hui (Tampines GRC) and Mr Leon Perera (Non-Constituency MP) on actions following the use in November of up to eight packs of dental equipment that had not been fully sterilised.

Dr Khor also explained that there were already "at least three layers of checks" in place at TTSH.

The person operating the sterilising machines was meant to ensure that sterilisation had been carried out.

The person unloading the equipment was meant to check that the colour tab had changed colour to indicate that sterilisation was complete.

It was also the job of the person using the equipment to check that the tab was the correct colour before using the equipment.

 
 

All three steps were not adhered to at TTSH on Nov 28 last year.

Once the error was discovered, the hospital immediately recalled all the packs, but eight were missing and all could have already been used on patients.

Following the incident, the National Healthcare Group, which runs TTSH, now requires one person to perform the entire sterilisation process. All staff involved in critical steps can be tracked and traced.

The MOH has also asked all healthcare institutions to heighten vigilance, step up competency training and conduct internal quality audits on their sterilisation process.

Dr Khor said that while the risk of infection was "extremely low" in the TTSH incident, "it is nonetheless a serious breach".

Counselling and disciplinary action has been taken against the 18 people involved, including warnings and financial penalties.

Dr Khor stressed that patient safety "is of utmost importance" and apologised that such an incident occurred.