Below are listed Infection Prevention And Control (IPAC) investigations that are older than 12 months.

Initial Report

Premise/facility under investigation (name and address) Brimley Dental Office
123 Montezuma Trail
Scarborough, ON M1V 1K4
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse September 2, 2016
Date of Initial Report posting  November 17, 2016
Date of Initial Report update(s) (if applicable) n/a
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • Inadequate reprocessing of critical instruments and devices
  • Inadequate hand hygiene performed by a dental healthcare provider between patients
  • No records documenting quality assurance testing of the Sterilizer
  • Inadequate chemical integrator (CI) used with packaged reprocessed instruments
  • No sharps containers are the point of use
  • Dental instruments and devices not stored in packages after reprocessing (eg. Dental handpieces, critical instruments, dental burs)
  • Expired healthcare products (local and topical anaesthetic) stored in patient care area with non-expired products
  • Alcohol based hand rub did not meet Health Canada standards

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college?  Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Recommendations include:

  • Ensure all re-usable critical instruments are reprocessed in the Sterilizer within the appropriate sterile packaging prior to use on another patient
  • Ensure quality assurance is conducted and documented on a daily basis
  • Document the reprocessing and related quality assurance
  • Ensure that where required, all chemicals used at the Premises have the required a Health Canada Drug Identification Number (DIN) and that the chemicals are appropriate for use in the healthcare setting (eg. Alcohol Based Hand Rub requires a minimum concentration of 70% alcohol)
  • Discard all expired chemicals and products used in patient care at the Premises
  • Place an approved sharps bin at point of use in any and all rooms where sharps are used, in addition to the reprocessing room
  • Ensure Infection Prevention & Control (IPAC) policies and procedures are available on site that all staff at the Premises are following IPAC best practices acceptable to the Royal College of Dental Surgeons of Ontario (RCDSO) while providing dental care
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order served on September 9, 2016

Written Order served on September 23, 2016

 

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) n/a

Final Report

Date of Final Report posting: February 16, 2017
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Verbal Order served on September 9, 2016

Written Order served on September 23, 2016

Brief description of corrective measures taken  As of September 9, 2016, all previously identified IPAC issues were corrected except the following:

  • Failed to ensure regular preventive maintenance, including regular cleaning schedule of the sterilizers, is performed according to manufacturer’s instructions
  • All work surfaces are to be of non-porous and cleanable material
  • Failed to ensure eye wash facilities are available wherever reprocessing is done

As of January 27, 2017, all previously identified IPAC issues were corrected except for :

  • Failed to ensure regular preventive maintenance, including regular cleaning schedule of the sterilizers, is performed according to manufacturer’s instructions
Date all corrective measures were
confirmed to have been completed
n/a

 

 Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) On January 27, 2017, TPH was informed that the outstanding item was being addressed

If you have any further questions, please contact:

Name Danielle R. Steinman
Title Manager, BBD IPAC Team

Control of Infectious Diseases/Infection Control

Email address danielle.steinman@toronto.ca
Phone number 416-338-8400

Initial Report

Premise/facility under investigation (name and address) MCI The Doctor’s Office at Richview
250 Wincott Drive Unit 2
Toronto, ON M9R 2R5
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of  IPAC lapse 10/03/2016
Date of Initial Report posting  25/04/2016
Date of Initial Report update(s) (if applicable) n/a
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • No IPAC signage or access to hand hygiene at clinic entrance
  • Inadequate environmental cleaning, and environmental surfaces in various states of disrepair in clinical areas
  • Non-critical medical equipment not disinfected between patients (eg. stethoscope)
  • One sink used for hand hygiene and reprocessing of instruments
  • No dedicated area for reprocessing instruments in the reprocessing room creating the potential for cross-contamination between clean equipment and patient samples
  • Inappropriate re-use and reprocessing of single-use devices (SUDs)
  • Risk of contamination of clean items
  • The clinic autoclave was never challenged using a biological indicator (i.e. spore test)
  • No IPAC policies and procedures

 

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college?  Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • IPAC signage and access to hand hygiene to be provided at clinic entrance
  • Ensure that all non – critical medical equipment is disinfected between patients
  • Environmental cleaning and maintenance of environmental surfaces in clinic areas to be done on a regular basis.
  • Ensure that there is dedicated sink for cleaning and disinfecting of instruments. This sink must not be used for hand hygiene, food preparation or any other purposes
  • Ensure that dedicated areas are present to prevent potential cross-contamination (eg. Medication preparation area, clean/sterile items, dirty/soiled area, reprocessing area, patient samples area etc.)
  • Ensure SUDs and not re-used between patients, or reprocessed as per manufacturer’s instructions and the PIDAC Document ensuring all clean supplies are stored in a way to protect them from contamination Perform daily spore testing (using a biological indicator) on Autoclave. Document all spore testing results and keep these records on site.
  • Create and implement IPAC policies and procedures
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order Issued on March 17th, 2016

 

Initial Report Comments

Any additional comments  (Do not include any personal information or personal health information) On March 17, 2016, TPH served a verbal order requiring the clinic to immediately discontinue use of autoclave until further notice by TPH.

On March 24/2016 a re-inspection was conducted at the clinic.

Corrective measures observed:

  • IPAC signage and hand sanitizer at front entrance  Environmental cleaning completed
  • Non – critical medical equipment was being disinfected between patients
  • Floors, walls and ceilings were smooth
  • A dedicated sink for reprocessing of instruments
  • Dedicated areas organized with labels in the back room such as medication preparation area, clean/sterile items, dirty/soiled area, reprocessing area, patients samples area
  • Only single-use blood collection tube holders used and discarded after each use
  • All clean supplies are stored in a way to protect them from contamination
  • TPH observed 2 successful(PASS) spore tests from autoclave

Interim Report

Date of Interim Report posting: 25/07/2016
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
04/18/2016
Brief description of corrective measures taken All items remain in compliance from initial posting from 04/25/2016.

Outstanding item: IPAC policies and procedures partially outstanding

Date all corrective measures were
confirmed to have been completed
22/07/2016

Final Report

Date of Final Report posting: 17/11/2016
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
 n/a
Brief description of corrective measures taken  All items remain in compliance from initial posting.
Date all corrective measures were
confirmed to have been completed
27/10/2016

 

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) n/a

If you have any further questions, please contact:

Name Danielle R. Steinman
Title Manager, BBD IPAC Team

Control of Infectious Diseases/Infection Control

Email address danielle.steinman@toronto.ca
Phone number 416-338-8400

Initial Report

Premise/facility under investigation (name and address) MCI The Doctor’s Office at Morningside Crossing
255 Morningside Avenue
Toronto ON M1E3E6
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of  IPAC lapse 22/03/2016
Date of Initial Report posting  25/04/2016
Date of Initial Report update(s) (if applicable) 07/25/2016 (update to Initial Report from 04/25/2016)
How the IPAC lapse was identified  Other
Summary Description of the IPAC Lapse Initial audit 22/03/2016 findings

  • No IPAC signage at the front entrance
  • Non-critical medical equipment not disinfected between patients (eg. stethoscope)
  • Inappropriate re-use and reprocessing of single use devices (SUDs)
  • Autoclave had no biological indicators (i.e. spore tests) performed on it
  • No IPAC policies and procedures

 

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college?  Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • IPAC signage to be posted at entrance
  • Ensure that all non – critical medical equipment is disinfected between patients
  • Ensure SUDs are not re-used between patients; or reprocessed as per manufacturer’s instructions and the PIDAC Document
  • Perform daily spore testing (using a biological indicator) on Autoclave. Document all spore testing results and keep these records on site .
  • Create and implement IPAC policies and procedures
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order issued on March 22/2016

 

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Update to Initial Report from 25/04/2016

Re-Inspection Audit Conducted 15/04/2016

  • IPAC signage posted at the front entrance
  • Non-critical medical equipment disinfected between patients (eg. stethoscope)
  • All SUD’s used as per manufacturer’s instructions and PIDAC documents
  • Daily biological testing performed on on-site Autoclave and records kept on site
  • IPAC policies and procedures outstanding

Interim Report

Date of Interim Report posting: 25/07/2016
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
04/25/2016
Brief description of corrective measures taken All items remain in compliance from initial posting from 04/25/2016.
Outstanding item: IPAC policies and procedures partially outstanding
Date all corrective measures were
confirmed to have been completed
22/07/2016

 

Final Report

Date of Final Report posting: 17/11/2016
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
 n/a
Brief description of corrective measures taken  All items remain in compliance from initial posting.
Date all corrective measures were
confirmed to have been completed
27/10/2016

 

Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) n/a

If you have any further questions, please contact:

Name Danielle R. Steinman
Title Manager, BBD IPAC Team

Control of Infectious Diseases/Infection Control

Email address danielle.steinman@toronto.ca
Phone number 416-338-8400

Initial Report

Premise/facility under investigation (name and address) Life Labs
520 Ellesmere Road, 1st floor
Toronto, Ontario M1R 0B1
Type of premise/facility: (E.g. clinic, personal services setting) laboratory/phlebotomy services
Date Board of Health became aware of  IPAC lapse 2016/02/18
Date of Initial Report posting  2016/03/02
Date of Initial Report update(s) (if applicable) n/a
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Re-use of visibly soiled blood collection tube holder for phlebotomy

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? No
If yes, was the issue referred to the regulatory college? n/a
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps TPH recommended Life Labs staff to:

  • discard blood collection tube holder if visibly soiled
  • follow manufacturer’s instructions for use and reprocessing of blood collection tube holders
  • review hand hygiene with staff to ensure compliance
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal order issued by TPH on Feb 18, 2016

 

Initial Report Comments

Any additional comments  (Do not include any personal information or personal health information) N/a

Final Report

Date of Final Report posting: 2017/01/12
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Verbal order issued by TPH on Feb 18, 2016
Brief description of corrective measures taken Re-inspection April 25, 2016

  • Discarding collection tube holder if visibly soiled
  • Reviewing hand hygiene with staff to ensure compliance

Re-inspection October 28, 2016

 

Date all corrective measures were
confirmed to have been completed
*April 25, 2016

*(Exception: Corporate procedure for managing blood collection tube holders

 

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) Head office required to update procedure corporately for locations, regarding following manufacturer’s instructions for reprocessing and management of blood collection tube holders.

If you have any further questions, please contact:

Name Danielle R. Steinman
Title Manager, BBD IPAC Team

Control of Infectious Diseases/Infection Control

Email address danielle.steinman@toronto.ca
Phone number 416-338-8400

Initial Report

Premise/facility under investigation (name and address) Shoppers Drug Mart
946 Lawrence Avenue East, unit 2
Toronto, Ontario
Type of premise/facility: (E.g. clinic, personal services setting) Pharmacy influenza immunization clinic
Date Board of Health became aware of  IPAC lapse November 11, 2015
Date of Initial Report posting  November 13, 2015
Date of Initial Report update(s) (if applicable) N/a
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Re-use of single use syringes on October 29th for immunization injections and potential contamination of multi-dose influenza vaccine vials.  Needles for injections were not re-used.

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes. Practitioner involved in the lapse is a member of the College of Pharmacy
If yes, was the issue referred to the regulatory college? College of Pharmacy contacted by TPH on November 3, 2015
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Education:

  1. Follow appropriate hand hygiene methods and appropriate use of gloves while providing care.
  2. Do not re-use single use devices, such as syringes.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Nov 3, 2015 TPH served a verbal order to practitioner to not give injections pending further TPH investigation

 

Initial Report Comments

Any additional comments  (Do not include any personal information or personal health information) The risk of bloodborne disease transmission from this lapse is extremely low.  All those affected by this lapse (clients from October 29th and some from October 30th) are being contacted by Toronto Public Health to notify them and are referred to their doctor to discuss any concerns/questions regarding testing

Final Report

Date of Final Report posting: October 21, 2016
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
November 3, 2015:

Toronto Public Health (TPH) conducted onsite audit and observed the Practitioner demonstrate injection practice.  TPH served a verbal order to Practitioner to not give injections pending further TPH investigation

Brief description of corrective measures taken November 12, 2015

TPH observed Practioner injection technique.
TPH observed IPAC issues. TPH provided verbal recommendations for proper IPAC technique.

January 26, 2016

TPH issued a letter to the Practitioner with written recommendations for proper IPAC technique when providing injections.
TPH required Practitioner to review proper IPAC practice for injection technique and not resume provision of immunizations until further notice. Toronto Public Health completed contact follow-up with all clients that attended the Influenza Immunization clinic held on October 29, 2015 at Shopper’s Drug Mart.

 

Date all corrective measures were confirmed to have been completed June 9, 2016

 

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) Sept 15, 2016

TPH was notified that Practitioner resigned as a member of the College of Pharmacy on June 9, 2016.

If you have any further questions, please contact:

Name Danielle R. Steinman
Title Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Email address danielle.steinman@toronto.ca
Phone number 416-338-8400