“Human Error” Blamed for Non-Sterilised Dental Tools Scare at TTSH, 18 Staff Disciplined

Following investigations, the National Health Group has blamed “human error” for the incident at Tan Tock Seng Hospital where non-sterilised dental tools were used for patient treatment, putting patients at risk of infections.

Up to 8 patients were treated with the equipment between 28 Nov and 8 Dec 2018.

TTSH has taken disciplinary action, including warnings and financial penalties, against 18 staff for the safety lapse.

Explaining how “human error” was the main cause of the incident, NHG said that dental instruments at the TTSH clinic are usually manually washed, put through ultrasonic machine sonication and air dried, before being steam sterilised.

The safety lapse involved a staff at TTSH’s dental clinic loading 8 packs of instruments in an autoclave machine used for steam sterilisation, but failing to start the process.

Another staff member later unloaded and stored the packs without realising that they had not undergone steam sterilisation.

The packs were also not verified to have been sterilised being they were used for treatment.

The Ministry of Health said that it will be reviewing incident reports from the NHG and TTSH together with results of its own investigation and will determine if further regulations or actions are necessary.

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