title: Infection control failures in a dental surgery--dilemmas in incident management.
abstract: 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.
authors.affiliation: Essex Health Protection Unit, 8 Collingwood Road, Witham, Essex CM8 2TT, UK. sally.millership@ntlworld.com
authors.forename: S E
authors.initials: SE
authors.lastname: Millership
authors.forename: A J
authors.initials: AJ
authors.lastname: Cummins
authors.forename: D J
authors.initials: DJ
authors.lastname: Irwin
mesh_terms: D017848:Blood-Borne Pathogens / Q000302:isolation & purification*; D003666:Decontamination / Q000592:standards*; D003762:Dental Instruments / Q000821:virology*; D003813:Dentistry / Q000592:standards*; D004866:Equipment Contamination / Q000517:prevention & control*; D017743:Equipment Reuse; D006801:Humans; D015994:Incidence; D019552:Infection Control, Dental / Q000592:standards*; D010865:Pilot Projects; D018570:Risk Assessment; D012307:Risk Factors; D017751:Safety Management; D013222:State Medicine; D006113:United Kingdom; D014777:Virus Diseases / Q000097:blood / Q000517:prevention & control* / Q000635:transmission