Dr. Lyne Giroux, Sudbury Ontario

Public Health Sudbury & Districts Infection Prevention and Control Lapse (IPAC) Report

Patients affected by this infection prevention and control lapse were mailed the following three items for reference and follow up:

Initial Report

Premise or facility under investigation:

From June 21, 2006, to June 30, 2010

Dr. Lyne Giroux

885 Regent St., Suite 300

Sudbury, ON  P3E 5M4

From March 5, 2018, to January 24, 2020

Dr. Lyne Giroux

336 Pine St., Suite 400

Sudbury, ON  P3C 1X8

Type of premise or facility:

Date the Board of Health became aware of the infection prevention and control lapse:

Date the infection prevention and control lapse was linked to the premise or facility:

Date of posting the Initial Report:

Source of the infection prevention and control lapse information:

Summary description of the infection prevention and control lapse:

From June 21, 2006, to June 30, 2010, and from March 5, 2018, to January 24, 2020, syringes were reused to withdraw additional doses of local anaesthetic from multi-dose vials for the same patient.

This practice could result in contamination of the multi-dose vials with blood borne pathogens. The multi-dose vials containing anaesthetic could then be used to fill other syringes for use on other patients resulting in the risk of transmission of blood-borne pathogens.

The use of previously used contaminated needles or syringes to access multi-dose vials is considered an infection prevention and control lapse.

The guidance on the use of multi-dose vials in Infection Prevention and Control for Clinical Office Practice (2015, PDF) is clear that when using multi-dose vials the provider must never re-enter with a used needle or used syringe.

The specific circumstances in this incident were reviewed by Public Health Ontario at the request of Public Health Sudbury & Districts in order to inform the agency’s risk assessment and determination of whether an infection prevention and control lapse occurred. Public Health Sudbury & Districts’ findings and actions are in line with the findings of Public Health Ontario.

Infection prevention and control lapse investigation

Did the infection prevention and control lapse involve a member of a regulatory college?
If yes, was the issue referred to the regulatory college?
Were other stakeholders notified?

Concise description of the corrective measures required:

The use of multi-dose vials for injectable medications and vaccines increases the risk of transmission of blood-borne pathogens and bacterial contamination of the vial and should be avoided. Patient safety should be prioritized over cost when choosing between multi-dose and single-use medication vials.

If multi-dose vials are selected for use, the following recommendations must be followed each time it is used:

Public Health Sudbury & Districts was informed by Dr. Lyne Giroux that on January 28, 2020, nursing staff were educated at a meeting on the guidelines for the use of multi-dose vials as outlined in Infection Prevention and Control for Clinical Office Practice (2015). All the multi-dose vials that were in use were removed and discarded as of January 28, 2020.

Please provide further details or steps:

Potentially exposed patients were identified by cross referencing clinic patient lists for the identified time periods against procedures that would have required local anaesthetic. These patients are being notified of the incident and advised of testing options. This was accomplished by regular mail on May 21, 202o through a package (letter, resources, and laboratory requisition) from the physician or owner of the dermatology clinic. This package was reviewed and approved by Public Health Sudbury & Districts’ Medical Officer of Health.

Date any order(s) or directive(s) were issued to the owners or operators: (if applicable)

If you have questions, please contact:

Cynthia Peacock-Rocca, Manager
roccac@phsd.ca
705.522.9200, ext. 279

Final Report

Date of Final Report posting:

Brief description of corrective measures taken:

Public Health Sudbury & Districts was informed by Dr. Lyne Giroux that on January 28, 2020, nursing staff were educated at a meeting on the guidelines for the use of multi-dose vials as outlined in Infection Prevention and Control for Clinical Office Practice (2015). All the multi-dose vials that were in use were removed and discarded as of January 28, 2020.

Date all corrective measures were confirmed to have been completed:

The clinic advised Public Health Sudbury & Districts on March 12, 2020, that corrective measures were completed by January 28, 2020. This was confirmed by Public Health Sudbury & Districts on March 13, 2020.

This item was last modified on June 29, 2020