Public Health Unit Infection Prevention And Control Lapse Report

Initial Report

Premises/Facility Under Investigation

Pitt Street Medical Clinic
1331 Pitt Street
Cornwall, Ontario
K6J 3T7

Type of Premises/Facility

Walk in Medical Clinic

Date Board of Health Became Aware of IPAC Lapse

September 30, 2021

Date IPAC lapse was linked to the premise/facility

September 30, 2021

Date of Initial Report Posting

November 15, 2021

Date of Initial Report Update(s)

How the IPAC Lapse was Identified


Summary Description of the IPAC Lapse

During the inspection, deficiencies in the reprocessing of medical devices were identified. The autoclave and reprocessing procedures were not documented nor understood by clinic staff. Devices were cleaned and soaked in a hospital grade disinfectant for 12 hours, packaged and then placed in a steam autoclave. No biological indicators were noted to be in use. The following items were reprocessed at the clinic: •Single use skin staple removers reprocessed from 2006 to 2009 and then from 2019 to July 28, 2021. •Reusable pelvic exam speculums reprocess from 2006 to 2009. •One reusable pelvic exam forceps reprocessed from 2006 to 2009 and then from 2019 to July 28, 2021

IPAC Lapse Investigation

Issue referred to regulatory college and/or other stakeholder notified?


If the Lapse Involved a Member of a Regulatory College, Was the Issue Referred to that Regulatory College?

Referral made to the Ontario College of Pharmacists

Were any Corrective Measures Recommended and/or Implemented?

Biological testing performed by the health unit failed. Reprocessing of medical equipment or devices will no longer occur at the clinic. Clinic owner and manager have decided to only use single use disposable medical devices.

Date any Order(s) or Directive(s) Were Issued to the Owner/Operators

Initial Report Comments

Important: Despite the lapse in practice identified, the risk of acquiring a blood borne pathogen with the use of the instruments is extremely low. This was based on the types of instruments potentially used and pre-cleaning practices which included an extended length of instrument soaking in an approved hospital grade disinfectant solution.

If you have any further questions, please contact:

Shawna Carr
Program Manager / Gestionnaire de programmes
613-933-1375 x 1212