Public Health Unit Infection Prevention And Control Lapse Report
Initial Report
Premises/Facility Under Investigation
Morrisburg Dental
41 5th street East
Morrisburg, Ontario
K0C 1X0
Type of Premises/Facility
Dental Clinic
Date Board of Health Became Aware of IPAC Lapse
May 3, 2023
Date IPAC lapse was linked to the premise/facility
May 3, 2023
How the IPAC Lapse was Identified
Self reported incident by dental clinic.
Summary Description of the IPAC Lapse
The clinic self reported the breach to the health unit as per their internal lapse protocol. It was identified that some dental instruments had not been sterilized and were used on patients by error.
IPAC Lapse Investigation
Issue referred to regulatory college and/or other stakeholder notified?
Referral made to Royal College of Dental Surgeons of Ontario.
Referral made to the College of Dental Hygienist of Ontario
Were any Corrective Measures Recommended and/or Implemented?
1.Ensure sterilized dental equipment or devices are not used until the chemical indicator (CI) are checked.
2.Ensure sterilizer mechanical display or USB is checked, verified, and signed for each cycle by the person sterilizing the dental equipment or devices. If not, then a Type 5 CI is placed in every package.
3.Update the current sterilization log to include a section that physical parameters of the sterilizer have been verified and met.
4.Ensure dental equipment or devices are only released when the biological indicator (BI) results are available. If quarantine pending BI results is not possible, evaluation of a Type 5 or 6 chemical indicator in a process challenge device (PCD) and the specific cycle physical parameters are used to justify the release of routine loads.
Initial Report Comments
Exposed individuals notified.
Interim Report
Date of Interim Report Posting
July 19, 2023
Brief Description of Corrective Measures Taken
Clinic is now following current best practices for cleaning, disinfection and sterilization of dental instruments and devices.
Date All Corrective Measures Were Confirmed to Have Been Completed
June 6, 2023
If you have any further questions, please contact:
Shawna Carr
Program Manager / Gestionnaire de programmes
ipac@eohu.ca
613-933-1375 x 1212