Saturday, August 25, 2007

Infection control failures in a dental surgery—dilemmas in incident management

Journal of Public Health Advance Access originally published online on June 22, 2007
Journal of Public Health 2007 29(3):303-307; doi:10.1093/pubmed/fdm038


Three separate incidents involving failure of decontamination of dental instruments were reported to our Unit in less than one year. We describe the risk assessment we undertook for the likelihood of detecting transmission of a blood borne virus infection. Even where 4000 patients attended the same dentist for seven years, there was no certainty of detecting even one person infected by the decontamination failure, while several people who had acquired infection by other routes would be identified. We conclude that these findings suggest that notifying patients is not usually justified.

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