Media

Incident Report of University Health Service Dental Unit

03 Nov 2012

 

The University of Hong Kong Health Service (UHS) Dental Unit has been contacting 250 patients who were treated from October 30 to November 2 at the clinic, after some dental instruments were found not having gone through all the procedures of sterilisation. UHS will invite patients to take a blood test to ensure that patients’ health would not be affected.  The incident has been reported to the Centre of Health Protection.

Under normal procedures, all dental instruments have to go through the following 4 steps for sterilisation:

1. Used instruments will be rinsed by water

2. The instruments will then be treated for 45 minutes in a thermal disinfector with high temperature of 93 degrees C with enzyme cleansing agent (it can dissolve blood and body fluid).

3. Medical staff will then inspect the instruments to ensure that the result is satisfactory, if not, the above will be repeated.

4. The final step is having the instruments sterilised in an autoclave by high temperature of 121 degrees C. When the process is complete, the colour labels of the instruments and packs will change colour to indicate that the instruments have been fully sterilised.

On November 2, a nurse of UHS found that colour labels of some instruments were not in the right colour which showed that they have not gone through the final step and reported the incident.

The patients in question include around 100 students, the others are staff and their family members. By this evening (November 3), UHS has contacted more than 100 patients, 86 of them have done the blood test. UHS will continue to contact the other patients tonight.

At the same time, UHS has immediately consulted three experts of the University’s Department of Microbiology. They are HKU Li Ka Shing Faculty of Medicine Department of Microbiology Henry Fok Professor in Infectious Diseases Professor Yuen Kwok Yung, Department Head Professor Patrick Woo and Assistant Professor Susanna Lau. Their initial opinion is that the instruments, having been sterilised by the first 3 procedures, the chance of bacteria and viruses left is very low.

However, it is necessary to invite the patients to have blood test to safeguard their  health. The test will investigate patients’ reaction to Hepatitis B, C and HIV. UHS has arranged the following locations for patients to take the blood test: HKU UHS and designated medical laboratories in Central, Wan Chia, Causeway Bay and Mong Kok. Initial results should be out in two days.

HKU has established an investigation panel composed of Deputy Vice-Chancellor Professor Roland Chin, Professor Yuen Kwok Yung and Dr Kitty Chan, Director of University Health Service, and possibly other members as well, to review the sterilisation procedures and establish better measures to ensure that similar incident will not happen again.

UHS has reported the incident to the Health Department and wishes to extend its sincere apologies to patients concerned.

For media enquiries, please contact: Ms Trinni Choy (Assistant Director (Media), Communications and Public Affairs Office) tel: 2859 2606 / 9464 3431 email: pychoy@hku.hk