Any number of infection control mistakes can happen in the practice, but there are ways to mitigate and rebound from these mistakes.
Remember the peppy song from the children’s show Thomas and Friends, “Accidents Will Happen”? The point of the song was to let kids know that accidents do happen and that the best way to recover is to learn your lesson and move on. The same can be said of infection control mistakes at the dental practice, but mistakes aren’t just “oopsie” moments. If a mistake is serious enough, it can come with hefty fines and maybe even some damage to a practice’s reputation.
“Some practices receive significant monetary fines and, in the most severe cases, practices have been shut down,” says Lisa Kane, DMD, owner of Dental Office Compliance of New England. “It depends on the mistake, how often you’re making the same mistake and what your response to it is.”
The consequence of a mistake has a lot to do with the severity of it.
“Was there a risk of disease transmission?” Jackie Dorst, RDH, BS observes. Dorst is an infection prevention consultant and speaker. “Was it a one-time occurrence or was it something that had been ongoing and exposed multiple patients? For example, a change in a procedure or a change in a product could have exposed multiple patients before the lapse was noticed and corrected.
“The CDC even has a page on risk assessments and conclusions and source documents,” she continues. “It gives specific instructions to the approaches and the resources that a practice must follow after an incident. It says to evaluate the risk and manage infection control breaches that could be identified in healthcare settings or in the dental office.”
Safety breaches are sorted by CDC into 2 categories – Category A and Category B, determined by the risk severity.
“If some sort of a breach happens, you have to decide how serious it is,” Dr Kane adds. “There’s Category A, which involves a breach with a high risk of transmission – if you use the same needle on 2 people or something that is definitely high-risk. And then Category B, which entails less risk of passing on some set of bloodborne pathogen. So, depending on what it is, if it’s the first category, you’re going to call the patients involved and follow proper post-incident guidelines. They should be tested for HCV, HBV, and HIV.”
To reduce risks to patients, it’s prudent to follow best practices in the first place.
“My advice is to try to avoid things from happening in the first place,” says Dr Kane. “You can do that by having written standard operating procedures and being really diligent about training and cross-referencing. I always tell people, before you open packages, make sure the autoclave tape has changed – have a lot of touch points to double check that proper procedures are being followed and instruments used on patients are being monitored correctly.”
“We didn’t know…”
The most insidious incidents occur when practices simply don’t know that they’re making a mistake. Some of that can be the result of simple ignorance, but some of that also can be chalked up to the times.
“Especially as we’ve been through the pandemic for more than a year, there have been so many challenges for dental offices where there were product shortages,” Dorst observes. “Maybe they had to use a disinfectant that they had not used before, or they couldn’t acquire the type of masks or disposable clinic jackets that they were wearing before the pandemic. We all know the challenges that we’ve had during the pandemic of purchasing the correct personal protective equipment (PPE), and additionally there’s might have been a turnover or change in dental office personnel.”
That turnover in the practice can lead to confusion and a breakdown in proper training.
“Some practices may have had 1 or 2 team members that left, for whatever reasons. Maybe they were older or immunocompromised and decided the risk during this pandemic was just too great for them to work in healthcare,” Dorst says. “And the office may have hired new team members and all those factors using new products, new team members and supply shortages, can contribute to lapses and breaches in infection control.
“So, now’s a good time for them to review all infection control protocols,” she continues. “And their very best source is the CDC checklist that is provided in the Summary of Infection Prevention Practices in Dental Settings. It is an editable PDF document that reviews all infection prevention protocols such as hand hygiene, PPE, disinfecting surfaces, cleaning instruments, packaging instruments, sterilizing instruments and dental unit water line maintenance.”
Incorrectly packaging instruments and sterilizer utilization are some of the biggest sources of infection control mistakes.
“That’s very often an area when I see a sterilization breach such as the package is not sealed correctly, or maybe the cassette doesn’t have an internal indicator,” Dorst observes. “Another potential sterilization breach is how to test their sterilizer, not using the correct biological monitor for the type and number of sterilizers. So, filling out the CDC checklist is an excellent way to review all infection control protocols. Another important element of the infection prevention program is that all dental offices must keep records and logs of each step of their sterilization process. So, if they’re using, say, an ultrasonic cleaner for cleaning their instruments, they should maintain a log of when the solution is changed and when the ultrasonic’s sonication efficacy is tested.”
“Keeping a sterilizer record of each time they run a sterilization cycle, the time they started it, the time that it ended, did the cycle complete, and did all the indicator package indicators turn color,” Dorst details. “Those are all validation and verification that the system is working. So, all of the record keeping and doing procedures correctly is an important part of preventing breaches. And we all know the saying that ‘an ounce of prevention is worth a pound of cure’.”
Ensuring mistakes don’t happen isn’t difficult or daunting, it just requires thoughtful effort on the practice’s part.
“When I go into an office, I see clinical care items that are not sterilized properly. Once you take something out of the sterilization bag, it is no longer sterile. Those instruments should be used immediately,” Dr Kane adds. “People think that once something has been sterilized, it is always sterile. So, if you have burs or rubber dams or clamps or whatever, and you autoclave them in a bag, but then you take them all out and set them up in the drawer, those are no longer clean.”
Following good infection prevention protocols, even seemingly mundane ones, helps reduce the risks.
“Go on the board website for whichever state you’re in,” Dr Kane advises. “Look at the regulations, read the CDC and OSHA guidelines. If the regulations seem overwhelming, you can hire a consultant. Have someone come in and do a mock inspection – a walkthrough. It’s always good to get another set of eyes, because it’s like your house. You walk in and you have this thing on the counter that you don’t even notice anymore, because it’s always there. And someone else comes in and says, ‘Wait a second. Why is that sitting here?’
“That’s why I feel it’s good to get some really good training, have standard operating procedures, so everyone’s doing things the same way, everybody understands what they’re doing, and everyone knows their role, and everyone takes ownership.”
If an accident is severe enough, it can result in steep fines, but that may not be the worst penalty. In some cases, the incident may have to be reported to governing bodies – possibly even the media – and the practice’s reputation may take a hit. It all starts with the risk management assessment.
“You first look at the risk of communicating a disease from 1 patient to the next or that patient acquiring an infection because of the breach,” Dorst says. “The most frequent serious breaches where a patient would be put at risk are, maybe, the reuse of injection needle or accessing multiple dose vials with a contaminated needle. In dentistry, one of the most frequent breaches is not sterilizing handpieces but just wiping the handpieces with disinfectant between patients, which could put patients at risk. If this practice continues for an extended time, then a large number of patients could be at risk for infections – larger than say, 200, 500 patients – then the practice must notify not only the patient but notify the media also.”
Nobody wants mistakes to happen, but if they do, it’s best to learn the lesson and make sure they don’t happen again. Obviously, the practice doesn't want to pay hefty fines or risk the reputation, but even worse is the potential for harm to team members or patients.