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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Digital Esthetics. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
While practices have their patients’ best interests at heart, breaches can still occur. Responding appropriately will help to mitigate harm to both the patient and your practice.
While the emphasis on infection prevention is, of course, “prevention,” the unfortunate reality is that sometimes infection control breaches do occur. Should such an incident happen, how it’s handled can be critical for patients, staff and the practice.
It’s easy enough to bury one’s head in the sand and pretend nothing happened or try to pass the buck, but ultimately there’s an established protocol that should be followed.
“If an infection control breach occurs, it can fill even the most seasoned infection control coordinator with dread,” says Karen Daw, a speaker and consultant. “Fortunately, the Centers for Disease Control and Prevention provides guidance in the form of the ‘Steps for Evaluating an IC Breach.’”
Identify the problem
The first step is to ascertain what exactly happened, and then follow through on the steps necessary to protect the public and your practice.
“When a breach happens, there is the risk of it not getting reported if there is a culture of blame in the office and not a culture of safety,” says Jackie Dorst, RDH, BS, an infection prevention consultant and speaker. “A culture of safety encourages transparency, and if there is an error, or there’s an oversight, that transparency allows you to identify it and then to identify the corrective measures and how to prevent this from happening in the future. The entire dental team contributes to the solution to prevent that from happening.
“If, on the other hand, there’s a culture of blame, to say, ‘Well, she didn’t do this, or we didn’t have that,’ or negativity, then there’s the temptation to hide the error because of potential repercussions for any team members involved in the error,” she continues. “You can understand how that’s not a healthy business environment or a healthy clinical environment.”
Communication and the decision to recognize the problem are vital.
“If a team member suspects a breach, they should report it immediately to the infection control coordinator,” Daw says. “Therefore, the office should be proactive and educate the team on preventing breaches, and if one has occurred, that the office policy includes reporting in a ‘blame-free’ environment. The last thing a doctor wants is an employee that fears speaking up about safer practices or an infection control incident. Reassuring everyone that reporting is in the best interest of all involved and living by example can ensure the next best steps are taken.”
The next step is to get a complete and accurate picture of the breach.
“The timeframe during which the breach occurred and determining which patients may have been affected as well as a review of source patient bloodborne pathogen infection status," Daw says. "It is possible that the patient has not disclosed this or has not been tested. For example, in the case of hepatitis C, a patient may have been asymptomatic and therefore never bothered to be tested.
“If the breach is from a possible bloodborne pathogen - hepatitis B transmission, hepatitis C transmission, or HIV - was it due to improper sterilization, or was it due to an unsafe injection practice?” Dorst asks. “It may have been a non-bloodborne pathogen breach, such as the children who are infected with mycobacterium abscesses. When the first incident happened in Georgia, it was thought to be from improper sterilization, later identified as dental unit waterline contamination.”
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Notify key stakeholders
At this point, it’s appropriate to make other entities aware of the issue.
“These individuals should be identified ASAP and may include epidemiologists, risk management teams, the local health department, and dental licensing or other regulatory agencies,” Daw says.
According to the CDC, “Key partners will vary depending on the situation but should be identified and engaged as early as possible. Parties to consider involving include: infection control practitioners and hospital epidemiologists from the involved facilities; representatives of facility risk management teams; affected state and local health departments; affected healthcare providers; and licensing or other regulatory agencies, if appropriate. Occasional infection control breaches have been reported in the context of medical malpractice or substance abuse by healthcare providers. Such factors might influence transmission or complicate an investigation.”
Qualitative assessment of the breach
Not all breaches are created equally, and the practice’s response is proportional, based on which type of breach occurred.
“You’re going to have a Category A breach, which is a high risk. There is a high risk of a blood exposure here,” Dorst says. “Or a Category B breach, that’s a lower risk of a blood exposure and not as serious a risk of infection to patients. Once you’ve identified the type of breach, now you have to decide are you going to notify the patients? Was it so serious, a Category A, that patients must be notified and tested? Or was it a Category B and less serious?”
“Category A includes egregious breaches, like the reuse of needles and syringes,” Daw adds. “Category B breaches are not likely high-risk but still warrant reporting, as the possibility of risk is greater than zero. An example might be not following proper instrument reprocessing.”
Patient notification and testing
While it is, of course, important to identify and respond to all breaches, some breaches may not warrant notifying the world. In some cases, unnecessary worry and concern could be caused.
“Notifying and testing patients are included under Category A breaches,” Daw says. “In other words, it has been determined that there is high likelihood of bloodborne pathogen transmission. For Category B breaches, notifying and testing patients is determined by a large number of variables. This is where partnering with a consultant may benefit the practice.”
“How serious was that risk?” Dorst adds. “The other concern would be if you make a notification of it, what’s going to be the public response to that? What’s going to be the public concern from it? It might be that there was a real low risk, really no evidence of risk. But there was a breach, maybe just a sterilizer wasn’t monitored for a month, spore tests weren’t done on it, but instruments were still being sterilized. The indicators were still changing color. But still, that’s a breach. The sterilizer wasn’t being monitored.
“If you notify patients that were being seen in that treatment facility, would it cause public concern in a breach to the point that it could be a negative?” she adds. “Maybe those patients don’t go to the dentist for four or five years. It has historically happened that we have had patients that would actually stay away from the dentist because of concerns. And that was such a minor breach that the public alarm was not justified from it.”
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Communication and logistics
In many ways, once notifications are issued, the real work begins. Expect more questions and more inquiries, both from concerned patients and, quite possibly, the media.
“The PR team and upper management should decide on a uniform messaging strategy and the best method for notifying patients,” Daw says. “The practice should also be prepared for media inquisitions, press releases and potential legal issues.”
“Once they identify the patients, and then have contact information for the patients, it’s appropriate to notify the patients by telephone call, by written letter, by email and then by media,” Dorst says. “Because we know that in our mobile society, some of those patients may have moved, their contact information may have changed, and they may not receive those notifications that are individually sent out. So, then a public service announcement would need to be made.”
Once notifications have been made, a plan must be in place to handle testing to establish which, if any, patients were affected.
“What are the logistics of how you’re going to test those patients?” Dorst asks. She points to the base of an Oklahoma practice where hepatitis C was transmitted to a patient. “They tested over 8,000 patients total, so that was a huge logistical concern. How do you test all those patients?”
While practices have their patients’ best interests at heart, breaches can still occur. Responding appropriately will help to mitigate harm to both the patient and the practice.
“Even with the best of training and guidance, an infection control breach could occur in the practice,” Daw says. “Hopefully, the office by now has recognized the importance of appointing an infection control coordinator. This person, per the CDC, is knowledgeable or willing to be trained in matters related to infection prevention. The Organization for Safety, Asepsis and Prevention is a nonprofit organization with great resources to support the person in this role. My clients are enrolled in their program, so they have the best and latest information at their fingertips.
“An infection control coordinator will work with the doctors and practice manager to figure out what occurred, next steps and preventative measures,” she continues. “They will also work with the public relations and social media teams to provide proper reassurance to patients and the general public.”