Error causes health scare at dental clinic

“It was human error and we are accepting responsibility,” Kevin Kelley, CEO of Community Health Centers of Lamoille Valley, said in an interview on Friday. “It’s our fault.”

On Tuesday, Dec. 6, it was discovered that 12 pouches of tools at the clinic hadn’t been properly sterilized. The tools had been used on Friday, Dec. 2, and Monday, Dec. 5.

Staff quickly began contacting the 59 people on whom the tools could have been used; they called through that day, into the evening, and again Wednesday morning.

“We wanted to move very quickly on this to ensure the safety of our patients,” Kelley said.

The clinic was closed Wednesday morning to free up more staff to make the calls, but had reopened by the afternoon. Staff also contacted local news stations and sent a memo to patients to let them know.

“We really wanted to get the word out to our patients,” Kelley said.

Staff members figured out whom to contact by figuring out which appointments would have required the use of the tools; initial reports put the figure at 61 patients, but it was later reduced to 59.

The staff also examined the medical records of the 48 patients who had visited the clinic in the few days prior to that Friday. According to Kelley, none of those individuals have hepatitis B or C or HIV.

Now, testing for all three is being offered to the 59 patients as a precaution.

“It’s a very low-risk situation,” Kelley said.

Officials at the Vermont Department of Health agree with that.

“It’s very low risk; Vermont is a low-incident state for HIV and for viral hepatitis,” Patsy Kelso, the state epidemiologist for the department, said.

“It’s not a zero-risk situation,” said Ben Truman, media relations for the Vermont Health Department, but his department hasn’t heard or seen anything to indicate a “high-risk situation” for the patients.

“It seems to be fairly low risk,” Truman reiterated.

According to the memo sent to patients who were offered testing, “the background rates of hepatitis and HIV are very low in our community” and the rate of transmission is also very low, even when there is known exposure.

By Tuesday morning, Dec. 13, a total of 40 patients had scheduled tests; 11 more declined testing, citing the extremely low risk factor. Staff at the clinic had left messages with the eight remaining patients, but hadn’t heard back yet.

“Now it’s going through the testing process for those patients who wanted it,” Kelley said. That means an initial screening, another check six weeks later, and another text six months later.

“That’s the normal timeline for these tests and results,” Kelley said.

David Coddaire, the executive medical director for the Community Health Centers of Lamoille Valley, is also available to speak with patients about the issue.

The error in sterilization occurred after the tools had already been washed. Dental equipment is normally washed and then run through an ultrasound to ensure all solid particles have been removed. It’s then dried, put in a pouch and heated in a sterilizer to kill any microbes.

Test strips are also inserted into the pouch to indicate the tools have been heated to the necessary temperature; the 12 pouches at the Morrisville clinic that raised red flags were missing those test strips.

The memo sent to patients stated that “there could have been clean but non-sterile instruments used on our patients.”

Kelley is operating under the premise that the tools weren’t sterilized.

“We are assuming they weren’t sterilized. If there’s no strip, the process wasn’t completed,” Kelley explained. “We do know they were cleaned.”

In-house sterilization is common among dental practices, according to Kelley. Moving forward, his organization will be looking at steps to ensure the error doesn’t happen again.

“Our first priority was notifying our patients. The second is putting new checks and balances in place,” he said.

One step has already been added; from now on, employees who clean and sterilize equipment will put their initials on the packages they are responsible for.

“We expect to add a couple of more steps,” Kelley said.

Kelley acknowledged there’s always fallout from an incident like this, but added that one patient has already come to the office and hugged one of the staff dentists in thanks for the quick reaction.

Clinic staff members notified the federal Centers for Disease Control and Prevention and the Vermont Department of Health about the problem as soon as they became aware of it.

“We’ve been providing assistance to ensure the public is getting the information they need,” said Truman. “The clinic has been doing a very good job on that front.”

Truman and the staff at the clinic have also been working with Vermont 211, the information hotline, to prepare operators there with how to deal with any calls from concerned patients.

At this point, Kelley does not believe the federal agency will require follow-up inspections at the clinic, but he wasn’t sure on the next steps.

He declined comment when asked if the failure to properly sterilize the tools had led to any disciplinary action among the staff.

“We aren’t addressing employee issues at this point. We are focused on the patients right now,” Kelley said.

In the future, one step may be increasing how much information and training the staff gets about the sterilization process.

Any patients who had appointments on Dec. 2 or 5 and who haven’t heard from the clinic should call either the dental clinic at 888-7585 or the main office of Community Health Services at 851-8608.