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
613-933-1375 x 1212