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How to resolve an infection control breach

09 March 2020

Dr A, a recent graduate, had worked at her practice for seven months. Prior to commencing patient care, Dr A familiarised herself with the infection control protocols and procedures at her place of work; she was confident and comfortable that this area was suitably covered by the ethical and conscientious staff and management.

Following a hectic previous day in the clinic, Dr A commenced patient care on her first patient of the day: a routine examination and scale and clean. The morning proceeded uneventfully until about four patients into the day, when the practice manager interrupted Dr A during an appointment for whitening impressions to request a private word. Dr A excused herself and left the surgery. The practice manager announced that a potential infection control breach had been identified, as they could not be sure that the last autoclave cycle had been successful. Regretfully, a locum dental assistant had not identified this and had circulated the potentially unsterilised packs throughout the clinic.

Dr A recommended that all practitioners cease work until the extent of the breach could be identified, returned to her patient and organised the whitening tray insert appointment for the patient. Fortunately, this patient had only had impression trays used, no other equipment.

Dr A then contacted Dental Protection regarding the next steps and a specialist dentolegal consultant gave the following advice:

• Stop all treatment and identify and remove all potentially affected equipment.
• Identify which patients, if any, have had the equipment used on them.
• Notify these patients (the dentolegal consultant gave guidance on the phrasing to use) and recommend that they seek baseline testing for blood borne viruses, for which the clinic will pay.
• Reassure these patients that the practice is assessing the potential breach, to ensure it is not repeated.
• Audit to assess how the breach occurred and ensure it does not happen again.
• Increase the understanding of all the staff, without apportioning blame.

These steps were taken and all the impacted patients felt increased confidence in the practice because they valued the transparency. Fortunately, all blood tests were clear and the practice undertook a comprehensive audit to ensure there were no shortfalls, and also attended an infection control CPD course.

Learning points

Infection control breaches usually occur due to oversight or a lapse in concentration.

If and when they do occur, it is critically important to cease treating patients to ensure the breach does not continue.

Transparency with affected patients is key, and Dental Protection can assist in the words to use to explain what has happened to a patient.

It is prudent to check the bags of your equipment to ensure that the chemical indicator has changed colour and also that the bag is dry and intact.


These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits Dental Protection members enjoy as part of their subscription. 
For more detailed advice on any issues, contact us

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