Quality Management System: addressing risks and opportunities

 

 

 

 

 

 

 

Another blunder from our national health institution in recent times.

It has been widely reported in the media on National Dental Centre of Singapore (NDCS)’s sterilisation misstep.

 

The NDCS said that 72 patients received treatment with dental instruments that were not fully sterilized. A staff member discovered the lapse on June 5 and the packs were recalled from the clinics. The instruments—such as probes, mirrors and orthodontic pliers—had gone through machine washing and thermal disinfection, but had not completed the final step of steam sterilization before they were taken for used.

 

The centre said the risk of infection is “extremely low” given that the first 2 steps of the sterilization process remove 99.99% of organisms, including virus. Everyone knows low risk doesn’t mean no risk, no?  

Preliminary internal investigations showed “the origin of the incident was human error”, this is obviously a case of a major lapses of NDCS’s quality management system. The effectiveness of a quality management system is as good as its weakest link in the whole process. Unless the 3-step sterilisation process is fully automated, the risk of human error continues to be critical factor in this process-step, especially when it relates to safety and health of the patients (customers). Infections take time to develop, but the free consultation and medical coverage period in case these patients develop symptoms were not clearly defined by NDCS.  

  

While NDCS said the short-term solution was to put 2 staff to check the sterilization process to ensure it is fully completed before releasing the instruments for use, this is not sustainable and non-productive. The crux of the matter is really to determine the root to this problem and address all the risks and prevent such incident from recurring.

 

In this country, people are “tamed” and do not create public outcry for such health and safety incident and demand answers from the top management. Based on my observations, investigation outcome and corrective/preventive actions for such lapses in public health institutions are never published. Only those insiders know exactly what had happened and what actions had been taken.

 

While most people would accept this as “bad luck” or being out of the statistical bell-curve at the wrong time, I can never accept such blunder in our public and private health institutions. Our well-beings are at stake and at the mercy of these providers when we need to use them one day.