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Article: Management of an incident of failed sterilization of surgical instruments in a dental clinic in Hong Kong

TitleManagement of an incident of failed sterilization of surgical instruments in a dental clinic in Hong Kong
Authors
KeywordsSterilization
Dental
Clinic
Autoclave
Issue Date2013
PublisherElsevier (Singapore) Pte Ltd, Hong Kong Branch. The Journal's web site is located at http://www.elsevier.com/locate/inca/708700
Citation
Journal of the Formosan Medical Association, 2013, v. 112 n. 11, p. 666-675 How to Cite?
AbstractBackground/Purpose: We describe an investigation of an incident of failed sterilization procedure in a dental clinic. We aim to illustrate the principles in performing such investigations and to highlight some of the important checkpoints in sterilization procedures. Methods: In response to this incident, proper sterilization of all equipment was performed immediately. On-site investigation was conducted by the investigation panel to identify the cause and risks, to coordinate post-exposure management in affected patients, and to make recommendations to prevent similar occurrence of such incidents in the future. Results: The incident was due to a rare lapse of monitoring during the autoclaving cycle. A total of 127 sources and 250 exposed patients were identified within 24 hours of the discovery of the incident for risk assessment and testing for blood-borne viruses, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). A protocol was devised to manage the exposed patients against HBV, HCV, and HIV. Immunization and hyperimmune globulin for hepatitis B, and tetanus toxoids were given to the exposed patients where indicated. Exposed patients were followed-up for 6 months. We came to the decision that dating of instrument packages and signed documentation of each autoclave printout, color change of chemical indicators of each load and daily autoclave performance should be made mandatory with immediate effect. Conclusion: Rapid response is extremely crucial in minimizing the impact of this incident and relieving the anxiety of the affected patients. Proper recording and documentation of autoclave cycles and regular auditing should be enforced to prevent similar incidents. © 2013.
Persistent Identifierhttp://hdl.handle.net/10722/194633
ISSN
2015 Impact Factor: 2.018
2015 SCImago Journal Rankings: 0.607
ISI Accession Number ID

 

DC FieldValueLanguage
dc.contributor.authorCheng, VCCen_US
dc.contributor.authorWong, SCYen_US
dc.contributor.authorSridhar, Sen_US
dc.contributor.authorChan, JFWen_US
dc.contributor.authorNg, MLMen_US
dc.contributor.authorLau, SKPen_US
dc.contributor.authorWoo, PCYen_US
dc.contributor.authorLo, ECMen_US
dc.contributor.authorChan, KKCen_US
dc.contributor.authorYuen, KYen_US
dc.date.accessioned2014-02-17T02:01:31Z-
dc.date.available2014-02-17T02:01:31Z-
dc.date.issued2013en_US
dc.identifier.citationJournal of the Formosan Medical Association, 2013, v. 112 n. 11, p. 666-675en_US
dc.identifier.issn0929-6646-
dc.identifier.urihttp://hdl.handle.net/10722/194633-
dc.description.abstractBackground/Purpose: We describe an investigation of an incident of failed sterilization procedure in a dental clinic. We aim to illustrate the principles in performing such investigations and to highlight some of the important checkpoints in sterilization procedures. Methods: In response to this incident, proper sterilization of all equipment was performed immediately. On-site investigation was conducted by the investigation panel to identify the cause and risks, to coordinate post-exposure management in affected patients, and to make recommendations to prevent similar occurrence of such incidents in the future. Results: The incident was due to a rare lapse of monitoring during the autoclaving cycle. A total of 127 sources and 250 exposed patients were identified within 24 hours of the discovery of the incident for risk assessment and testing for blood-borne viruses, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). A protocol was devised to manage the exposed patients against HBV, HCV, and HIV. Immunization and hyperimmune globulin for hepatitis B, and tetanus toxoids were given to the exposed patients where indicated. Exposed patients were followed-up for 6 months. We came to the decision that dating of instrument packages and signed documentation of each autoclave printout, color change of chemical indicators of each load and daily autoclave performance should be made mandatory with immediate effect. Conclusion: Rapid response is extremely crucial in minimizing the impact of this incident and relieving the anxiety of the affected patients. Proper recording and documentation of autoclave cycles and regular auditing should be enforced to prevent similar incidents. © 2013.-
dc.languageengen_US
dc.publisherElsevier (Singapore) Pte Ltd, Hong Kong Branch. The Journal's web site is located at http://www.elsevier.com/locate/inca/708700-
dc.relation.ispartofJournal of the Formosan Medical Associationen_US
dc.subjectSterilization-
dc.subjectDental-
dc.subjectClinic-
dc.subjectAutoclave-
dc.titleManagement of an incident of failed sterilization of surgical instruments in a dental clinic in Hong Kongen_US
dc.typeArticleen_US
dc.identifier.emailCheng, VCC: vcccheng@hkucc.hku.hken_US
dc.identifier.emailWong, SCY: wcy288@hku.hken_US
dc.identifier.emailSridhar, S: sid8998@gmail.comen_US
dc.identifier.emailChan, JFW: jfwchan@hku.hken_US
dc.identifier.emailLau, SKP: skplau@hkucc.hku.hken_US
dc.identifier.emailWoo, PCY: pcywoo@hkucc.hku.hken_US
dc.identifier.emailLo, ECM: hrdplcm@hkucc.hku.hken_US
dc.identifier.emailChan, KKC: kcchan@hku.hken_US
dc.identifier.emailYuen, KY: kyyuen@hkucc.hku.hken_US
dc.identifier.authorityChan, JFW=rp01736en_US
dc.identifier.authorityLau, SKP=rp00486en_US
dc.identifier.authorityWoo, PCY=rp00430en_US
dc.identifier.authorityLo, ECM=rp00015en_US
dc.identifier.authorityYuen, KY=rp00366en_US
dc.identifier.doi10.1016/j.jfma.2013.07.020en_US
dc.identifier.pmid24034908-
dc.identifier.scopuseid_2-s2.0-84887021348-
dc.identifier.hkuros227721en_US
dc.identifier.volume112en_US
dc.identifier.issue11-
dc.identifier.spage666en_US
dc.identifier.epage675en_US
dc.identifier.isiWOS:000327169600004-
dc.publisher.placeHong Kong-

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