Churchill Glen Dental, Mississauga

Initial report

Premise or facility under investigation:
3020 Thomas St. A302, Mississauga, ON L5M 0R4

Type of premise or facility:
Dental Office

Date board of health became aware of the IPAC lapse:
2023-08-08

Date of initial report:
2023-08-17

Date of initial report posting:
2023-08-21

How the IPAC lapse was identified:
Dentist self reporting

Summary description of the IPAC lapse

Self reported IPAC lapse in reprocessing of dental instruments including:

• Reprocessing failure – critical and semi-critical dental instruments were cleaned but not sterilized and subsequently put into circulation.

Observed deficiency in reprocessing of dental instruments including:

• Use of an autoclave that is not on the active licensing list for Canada.
• Lack of quality monitoring and documentation of reprocessing process (e.g., chemical and physical indicator monitoring).

IPAC lapse investigation

Did the IPAC lapse involve a member of a regulatory college? Yes, RCDSO

Were any corrective measures recommended? Yes

Details of the corrective measures

• Re-sterilize all multi-use dental instruments.
• Replace autoclave.
• Create policies and procedures on reprocessing; including recall.
• Conduct formal staff education on reprocessing; including monitoring of physical and chemical indicators.
• Improve quality of sterilization logs.

Initial report comments and contact information

Additional comments: n/a

5 of 9 non-sterile instrument packages were removed from circulation prior to use and immediately reprocessed. Upon identification of lapse, all dental instruments were immediately reprocessed. An on-site investigation was conducted. Immediate actions were provided to the premise owner. Information and educational resources were provided for review. Dental clinic will proceed with patient notification.

Investigation ongoing.

If you have any further questions, contact:
Maureen Horn, Manager Health Services,
Peel Region
647-283-9739
Email infection control

Final report

Date of Final Report Posting

2023-10-05

State and date of all corrective measures that were confirmed to have been completed

2023-08-17: Autoclave was replaced and qualification testing was performed prior to sterilizing any dental instruments.

2023-09-09: Verification that all patients were notified by premise owner on August 24, 2023 of reprocessing failure and all multi-use dental instruments were re-sterilized prior to use on clients. Verification that staff education and improved sterilization logs have been implemented.

2023-09-21: Verification that reprocessing policies and procedures have been implemented.

Final report comments and contact information

Additional comments: n/a

If you have any further questions, contact:
Maureen Horn, Manager Health Services
Peel Region
647-283-9739
Email infection control