Management of an incident of failed sterilization of surgical instruments in a dental clinic in Hong Kong

Background/Purpose: We describe an investigation of an incident of failed sterilization procedure in a dental clinic. We aim to illustrate the principles in performing such investigations and to highlight some of the important checkpoints in sterilization procedures. Methods: In response to this incident, proper sterilization of all equipment was performed immediately. On-site investigation was conducted by the investigation panel to identify the cause and risks, to coordinate post-exposure management in affected patients, and to make recommendations to prevent similar occurrence of such incidents in the future. Results: The incident was due to a rare lapse of monitoring during the autoclaving cycle. A total of 127 sources and 250 exposed patients were identified within 24 hours of the discovery of the incident for risk assessment and testing for blood-borne viruses, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). A protocol was devised to manage the exposed patients against HBV, HCV, and HIV. Immunization and hyperimmune globulin for hepatitis B, and tetanus toxoids were given to the exposed patients where indicated. Exposed patients were followed-up for 6 months. We came to the decision that dating of instrument packages and signed documentation of each autoclave printout, color change of chemical indicators of each load and daily autoclave performance should be made mandatory with immediate effect. Conclusion: Rapid response is extremely crucial in minimizing the impact of this incident and relieving the anxiety of the affected patients. Proper recording and documentation of autoclave cycles and regular auditing should be enforced to prevent similar incidents.