Inspection of Dental Instruments John Cochran Division
Post date: Mar 11, 2011 10:47:51 PM
03/07/2011 12:00 AM EST
The purpose of this review was to determine the sequence of events involving alleged improperly cleaned and sterilized dental reusable medical equipment (RME); errors in reprocessing or sterilization; actions taken to correct deficiencies; and decisions related to patient notification of breaches in dental equipment reprocessing or sterilization at the STLVAMC. The dental RME reprocessing issues at the JCD were a long-standing problem that went unrecognized and unaddressed by Veterans Integrated Service Network (VISN) and STLVAMC managers. The Veterans Health Administration (VHA) self-identified the deficiencies and took actions to correct them; however, those actions did not always resolve the issues. Responsible managers did not verify the adequacy of RME reprocessing practices, nor did they assure that corrective actions were consistently implemented in response to VHA guidance and the Infectious Disease Program Office (IDPO) report. As a result, standard operating procedures (SOPs) were not developed in a timely manner for the reprocessing of dental RME, SOPs did not always match manufacturers’ instructions, and Dental Clinic staff had not received training on dental RME pre-treatment or reprocessing. We concluded that the occurrence of a patient-to-patient transmission of a blood-borne infectious disease at the JCD was unlikely. Nevertheless, the Clinical Risk Board adhered to the process outlined in VHA Directive 2008-002 when it recommended disclosure to 1,812 patients potentially affected by breaches in the cleaning and sterilization processes. We concluded that the STLVAMC promptly set-up and staffed its Dental Review Clinic, made appropriate efforts to contact identified patients, and provided adequate support and follow-up to patients. We recommended that the VISN Director require the STLVAMC Director to monitor the facility’s compliance with all appropriate elements of RME reprocessing, SOPs, staff training, and staff competencies as defined in relevant VHA guidance; ensure that the VISN Supply, Processing, and Distribution Management Board provides monitoring to ensure that SOPs based on manufacturer’s instructions are in place and that staff training and competencies are current; and take appropriate administrative actions based on the findings of the Administrative Board of Investigation and IDPO report.