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Failed sterilisation procedures pose health r -

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Failed sterilisation procedures pose health risk

Nicole Butler reported this story on Tuesday, November 17, 2009 12:18:00

ELEANOR HALL: To Queensland now where hundreds of patients who attended Bundaberg Hospital are
being tested for blood-borne diseases.

The patients were exposed to the danger of contracting HIV and hepatitis because the hospital
failed to follow standard dental sterilisation procedures.

The Bundaberg Hospital is already the subject of a court case involving patient deaths and fraud.
Now health authorities have launched an urgent review into its sterilisation procedures.

In Brisbane, Nicole Butler reports.

NICOLE BUTLER: The people of Bundaberg say they're losing what little faith they had in
Queensland's health system.

Almost five years ago a doctor was linked to patient deaths at the local hospital. Now 235 people
are being tested for the potentially deadly diseases HIV and hepatitis C after instruments weren't
sterilised at the Hospital's Dental Clinic.

BERYL CROSBY: In our local paper up here today there have been two patients who are obviously very
distressed and there was woman with five children who said, you know, this is stressful. It is the
wait. It is the wait of having to know, you know, whether something went wrong and the other girl
was apparently a 16-year-old who was very distressed and said she started crying which is a
obviously normal reduction when you think this might potentially, you know, be something that could
have devastating consequences.

NICOLE BUTLER: Beryl Crosby is president of the Bundaberg Patient Support Group.

She's been contacted by one of the dental patients who's been tested for blood-borne diseases by
Queensland Health.

BERYL CROSBY: She actually said, "are you aware that this has happened"? and I said, "yes I am
aware." And she said "look, they gave me the blood test," and she said, "I'm not concerned. I'm an
elderly lady". She said "they did offer me counselling but I am not concerned with counselling
either". She said, "what are they going to do, hold my hand," she said, "tell me it is going to be

She said they did say that the chances of getting anything were very low.

NICOLE BUTLER: Dental sterilisation procedures failed on the 6th of November but the problem didn't
come to light until the 13th.

BERYL CROSBY: No one knows why it took a week for Queensland Health to find out.

NICOLE BUTLER: Does that concern you? That there is that time?

BERYL CROSBY: Yes, of course it concerns me. It would concern anybody.

NICOLE BUTLER: But Ms Crosby says she is happy to hear that Queensland Health wasted no time in
contacting patients once the problem was detected.

BERYL CROSBY: They were notified on the 13th which was on Friday and on the next morning I think
their main concern was to contact every patient, which they did.

NICOLE BUTLER: The Sunshine Coast-Wide Bay Health Service says instruments used on the 6th of
November were cleaned but not sterilised and that most viruses are destroyed during that cleaning

Nonetheless it's urgently tracking down the 33 people who the instruments were used on first before
they were cleaned.

The service's district CEO Kevin Hegarty says if those people test negative to infectious diseases,
the risk to other patients is close to zero.

KEVIN HEGARTY: They are the 30, just over 30, that had the instruments used on them before the
sterilization and they were contacted immediately that we became aware of the problem on Friday.
Most were contacted by the end of the weekend. There's only a couple of exceptions that we are
still working on and full clinical histories are being taken.

So the fact that to date none of them are carriers of any blood-borne disease already further
mitigates the risk. The fact that the ...

NICOLE BUTLER: Mr Hegarty says procedures at the Bundaberg Dental Clinic are also being urgently

KEVIN HEGARTY: What is happening today is a full, what we call a HEAPS analysis - a human error and
patient safety review. It is a formal process where every aspect of what happened versus what
should have happened is in detailed exam and we have got independent infection control experts
flying in from Brisbane to be part of that.

As I say, we treat this very seriously and any action that is highlighted through this HEAPS
analysis, any required action to improve our process or whatever action they come up with
recommending, I'll be considering that tonight and putting that into place without any hesitation.

NICOLE BUTLER: The district health boss says initial inquiries indicate human error is to blame for
the failed sterilisation.

KEVIN HEGARTY: To the best of information I've got available to me at this stage, without
pre-empting the HEAPS analysis, is a slip up in a human element of that. So it is that element that
will be focussed on in this review.

NICOLE BUTLER: Queensland's Health Minister Paul Lucas is talking tougher.

He says Bundaberg health staff could be disciplined over the mistake.

PAUL LUCAS: This is a basic error that is just not acceptable. Dealing with sterilised equipment is
something that every day thousands and thousands of dentists Australia-wide do and for this
equipment not to have been sterilised properly and for it then to be used is just simply

ELEANOR HALL: That is Queensland's Health Minister Paul Lucas ending Nicole Butler's report.