Human error in dental stuff-up

November 19, 2009

FINAL investigations into a sterilisation fiasco at the Bundaberg Hospital Dental Clinic last November have confirmed the bungle was caused by human error.

The blunder caused almost 270 patients to be tested for hepatitis B, hepatitis C and HIV after it was discovered a breakdown in the sterilisation process had occurred and unsterilised equipment may have been used on some patients.

“The report found the breach was caused by the failure of a staff member to activate the autoclave — the machine that is the last stage in the sterilisation process,” Sunshine Coast-Wide Bay Health Service District chief executive officer Kevin Hegarty said.

The report will not be released.

MR Hegarty said a number of individuals had been named in the Queensland Health report, so a copy of the investigation’s findings would not be released, however a short summary was released.

It is unknown if disciplinary action has been taken against the staff involved.

As part of the recommendations, additional training would be provided for staff on sterilisation processes to help reduce the risk of a similar blunder happening again.

“Following the investigation, stringent validation of the completeness of the sterilisation process occurs at the time instruments are removed from the autoclave and on two further occasions before they are used on patients,” he said.

Member for Bundaberg Jack Dempsey said he hoped Queensland Health learnt a valuable lesson from this and other ordeals the hospital has had in the past.

“I would like to implore the Health Minister to have a manager based at the Bundaberg Hospital because the lines of communication would have been significantly reduced during the debacle,” he said.