Four National Dental Centre Singapore (NDCS) staff members, including supervisors and senior management, have been disciplined for hygiene lapses which led to the use of dental instruments that had not been fully sterilised.
The punishment included warnings and financial penalties, although details were not provided by SingHealth, which the NDCS is part of. Putting the lapse down to "human error", it said yesterday that the four had been found to have "fallen short in their level of vigilance and speed in escalation of incident management".
SingHealth added that measures have been put in place to improve the processes and culture at the NDCS to prevent a recurrence.
"We apologise for the lapses, and have started on corrective actions for improvement," it said.
On June 12, the centre said that 72 packs of instruments which had not been fully sterilised had been used to treat patients on June 5 and 6.
It has been in touch with all but four of the 714 patients who may have been treated with the equipment, and is also doing free blood tests for those who have requested it. These tests will check for the human immunodeficiency virus and hepatitis B and C.
NDCS said that it will try "various means" to reach the four patients.
An investigation was overseen by the SingHealth Risk Oversight Committee, and the findings were announced yesterday.
SingHealth explained that one staff member in the Central Sterile Supplies Department did not complete the final step of steam sterilisation for one batch of instruments in the late afternoon of June 5. These instruments were then dispatched to outpatient clinics.
Another staff member discovered the error, yet staff failed to recover all of the instruments that day. They tried again the next morning, but it was only after a third recall late on June 6 that all the instruments were recovered.
SingHealth attributed the initial lapse to human error, adding that procedural weaknesses and a lack of vigilance contributed to the failure to deal with it quickly.
For instance, staff who were aware of the error failed to properly assess its potential impact.
In addition, instrument packs typically have indicator strips which change colour when the sterilisation process is complete, but staff did not notice that these strips had not changed colour.
"This reflects gaps in the level of vigilance on infection control and patient safety, and, in this particular context, instrument sterility," said SingHealth.
"Specific measures have been taken to improve the competency of staff involved in the sterilisation and handling of instruments."
The Health Ministry said that it will review the findings of the investigation, and together with its own investigation and assessment, consider if regulatory action is needed.