Parliament: MOH ordered immediate safety reviews at all places following TTSH lapse

Dr Amy Khor says MOH has required healthcare institutions to strengthen their sterilisation systems.
Dr Amy Khor says MOH has required healthcare institutions to strengthen their sterilisation systems.

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

Senior Minister of State for Health Amy Khor told Parliament yesterday that MOH had also required them to strengthen their sterilisation systems and to en-sure 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 action taken following the use in November of up to eight packs of dental equipment that had not been sterilised fully.

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

The person operating the ste-rilising machines was meant to check that sterilisation had been carried out.

The person unloading the equipment was meant to check 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.

MOH had 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".

Disciplinary action has been taken against the 18 people involved, including warnings and financial penalties. They will also be counselled.

Dr Khor stressed that patient safety "is of utmost importance", and apologised that such an inci-dent occurred.

A version of this article appeared in the print edition of The Straits Times on January 15, 2019, with the headline 'TTSH lapse: MOH ordered immediate safety reviews at all places'. Subscribe