Counselling and disciplinary action, which include warnings and financial penalties, will be taken on 18 staff, including senior management and supervisors, who have not adhered to the expected requirements of quality and safe care of patients at the Tan Tock Seng Hospital (TTSH) Dental Clinic, where eight packs of instruments did not complete the final step of sterilisation (steam sterilisation).
In a press release on Tuesday (8 January), the National Healthcare Group (NHG) stated that it has completed the independent investigation into the incident at the hospital where the health practitioners used the unsterilised instruments for patient treatment between 28 November 2018 and 5 December 2018.
The NHG Review Committee is chaired by the Chief Executive Officer of the Institute of Mental Health (IMH), Professor Chua Hong Choon.
Following the incident, the NHG Review Committee, which includes experts from other health clusters, conducted a thorough review of the incident and has submitted its full investigation report with follow-up actions to the Ministry of Health (MOH) on 8 January 2019.
The committee stated that it has identified human error with a lapse in adherence to the established sterilisation process and verification protocol as the main cause of the incident.
“Specific recommendations have been made to improve the processes and systems at the TTSH Dental Clinic, including counselling and retraining of its staff,” it noted, adding its apology for the lapse and stated that it has started on improvements to ensure that quality and safe care remains paramount in all that they do.
According to the committee, a TTSH Dental Clinic staff found on 4 December 2018 that a dental instrument had not gone through the final step of steam sterilisation.
A a physical check of all dental instruments was then initiated the next day.
By 7 December 2018, it was confirmed that eight packs of instruments processed on 28 November 2018 did not complete the last step of the sterilisation process and could have been used for patient treatment at the Dental Clinic between 28 November 2018 and 5 December 2018.
Investigations showed that on 28 November 2018, a staff from the TTSH Dental Clinic failed to follow established protocol and loaded packs of instruments into the autoclave machine without initiating the steam sterilisation cycle (that is, the last stage of sterilisation).
Another staff subsequently unloaded and stored the packs, without realising that the packs had not undergone the final step of sterilisation. These packs were not verified for sterility before use.
On 9 December 2018, TTSH then began contacting all 575 patients who were treated at the Dental Clinic during the affected period to inform them of the incident and reassure them of the extremely low risk of infection.
Elective procedures at the Dental Clinic were suspended for a safety time-out from 8 to 12 December 2018.
During this period, all dental instruments were thoroughly checked and confirmed to have undergone the complete sterilisation process. Additional control measures were implemented to ensure that the sterilisation process was conducted in accordance with established processes and that the verification protocol was strictly adhered to.
Concurrently, staff awareness across the whole Hospital was heightened and the message of adherence to all processes for patient safety and care was reinforced.
The committee then assessed that the incident was a result of human error, contributed by a lapse in adherence to the established sterilisation processes and verification protocols.
In addition, weaknesses in some of the sterilisation protocols and work instructions were found to be contributing factors.
There were also gaps in the level of vigilance, it noted, adding that at various points in the process, staff had failed to verify the sterility of the instruments before use.
The committee also found that the timeliness of incident reporting was sub-optimal, where earlier escalation and faster response could significantly reduce the impact of the incident.
Corrective Actions
Following the TTSH Dental Clinic incident, TTSH has reinforced safety controls across the Hospital to improve vigilance and adherence to processes, so as to prevent any recurrence. Specifically, safety controls for the TTSH Dental Clinic have been fortified in the following key areas:
- Strengthening the Dental Clinic’s on-site sterilisation process and ensuring strict adherence by dedicated staff. The steps of loading the autoclave machine and starting of the sterilisation cycle must be linked. The unloading of packs after the sterilisation cycle must only occur after verification of sterilisation;
- Ensuring strict adherence to the pre-procedure protocol to check for the sterility of instruments before use;
- Optimising the workflow to improve the reliability of the sterilisation process to reduce the probability of human error;
- Strengthening incident reporting frameworks and ensuring escalation protocols are well
understood and adhered to by staff; and - Refining training, competency assessments and regular audits to reinforce staff compliance and understanding of the importance of safety checks that are built into the system, and with full adherence to all processes.
An Oversight Committee has been appointed by the Chairman of the NHG Clinical Board to oversee the implementation of the recommendations by the NHG Review Committee.
The Committee will share the findings and recommendations from the incident across all NHG institutions. External audits will be conducted to ensure that staff adhere fully to all processes for quality and safe care for patients.
Professor Philip Choo, Group Chief Executive Officer of NHG, said, “On behalf of NHG, we sincerely apologise for the incident. I would like to thank the Committee for its work in reviewing the incident and the recommendations put forth to improve our systems and processes.”
“Patient safety will continue to be our utmost priority, and we hold our staff to the highest standards of quality and safe care of patients. We will work harder to ensure that the well-being and safety of our patients are best served in all our institutions,” he added.
Netizens commented on this matter. Some asked, having to read the whole story, they did not understand where was the involvement of the 17 people when only a person failed to do the sterilisation.
Adrian Quek wrote, “Why 18 so many? I thought only 1 didn’t sterilize, 1 didn’t check. Now got 18 being punished. Curious actually what happen.”
Luke Wong wrote, “One person’s failure to follow safety protocol led to 18 being punished?”
Meanwhile, Mr Kelly Koh recalled that this was not the first time such incident happened.
He wrote, ‘This is totally unacceptable first and foremost. This is not the first and only incident. Before that also has this National dental at Outram similar incident. It seemed like did not learn the lesson at all.”
And a senior citizen said that the hospital charged him a lot and did not accept CHAS nor Pioneer Generation Card.
Ruak Redniham wrote, “And yet TTSH charged me for $15/for items like one plastic cup for rinse after dental examination, one piece of gauze that was inserted by dentist under my tongue, one piece of tissue paper for wiping my mouth. My bill came up to $50++. All this for a routine dental check and no cavities were detected. I paid only $15/ for similar dental examination a year later at a private clinic near my house and was given a senior discount using CHAS on top of it, hence, paying less than $15. Neither CHAS nior Pioneer Generation card was accepted at TTSH. And this is what looking after seniors and making medical care affordable is all about. Not the humbug and publicity about billions of dollars spending on healthcare for pioneer generation.”
