The challenges of faulty autoclaves: An IPAC lapse investigation

Abstract

An Infection Prevention and Control (IPAC) lapse at a physician’s office resulted in 54 non-compliance issues identified. Eight high-risk items were all associated with reprocessing. Examination of the autoclave revealed numerous structural concerns as it was a discontinued model of autoclave that originated from a retired physician. Three biological indicators were used to verify effectiveness of the autoclave but all of which failed. In consultation with Public Health Ontario’s IPAC team, contract tracing was needed as there was a risk to patients. Without adequate sterilization logs, the timeframe of patient records needed was the date after the autoclave was serviced by a technician until the date of the initial investigation. Lessons learned from this investigation include the need to reach out to suppliers to confirm compatibility of biological indicators with older model autoclaves and the importance of reviewing technician reports to understand when the device was last effective. With an increase in physician’s retiring during the COVID-19 pandemic, this case study highlights how discontinued autoclaves may be re-circulated into practice. This could result in similar issues faced by other public health inspectors.