Alpine Dental Brantford Lapse Report

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Initial Report

Establishment under investigation (name and address)	Alpine Dental Brantford 3-422 Grey St, Brantford, ON N3S 4X8
Establishment type	Dental clinic
Date health unit became aware of potential IPAC lapse	April 19, 2023
Date of initial report posting	April 27, 2023
Date of initial report update(s) (if applicable)
How was the IPAC lapse identified?	A complaint by a member of the public.
Date of on-site investigation	April 20, 2023

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college?	Yes; Royal College of Dental Surgeons of Ontario
If yes, was the issue referred to the regulatory college?	Yes
Were corrective actions recommended and/or implemented?	Yes
Date of any order(s) or directive(s) issued to the owner/operator (if applicable)	April 20, 2023
Summary description of the IPAC lapse	At time of the investigation instrument/equipment manufacturer’s instructions for use (MIFU’s) were not available for review During the complaint inspection it was observed that the disinfection and sterilization of reusable instruments on site did not follow Provincial Infectious Disease Advisory Committee (PIDAC) Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices (May 2013). X-ray holders were not sterile to the point of use. Inconsistent disassembling of instruments (e.g., two-piece mouth mirrors) observed of the inspection. Incorrect packaging of instruments prior to sterilization (e.g., instruments observed to be in a closed position; instruments were not properly packaged to allow steam to move around and through the item(s) and contact all surfaces)
Additional comments and/or updates to initial report	Staff members responsible for any or all steps in reprocessing are recommended to complete the Medical Device Reprocessing Techniques Online Course through the Medical Device Reprocessing Association of Ontario

Final Report

Brief description of corrective measures taken	Manufacturer’s instructions are currently being used for all instruments. Instruments where manufacturer’s instructions were not found have been removed from the dental clinic Instruments were repackaged appropriately to allow steam to penetrate through the item(s) and contact all surfaces Instruments (e.g., two-way mirrors) were disassembled prior to sterilization as per manufacturer’s instructions for use New X-ray holders were acquired by facility and reprocessed as per manufacturer’s instructions for use
Date all corrective measures were confirmed to have been completed	2023-04-26
Date of final report posting and/or any date of any updates to final posting	2023-06-20
Date of follow-up to confirm corrective actions taken and completed	2023-05-01
Additional comments