Sterilization Breakdown: A Dentist's Shocking Discovery and its Aftermath

You can talk to an employment law attorney about this one, but I said I would consider terminating that associate. I really would, who just let this happen. Not to say that they were the only one at fault, but I felt that a head should roll because of this. This is a terrible violation that could destroy this doctor's career. Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. As we kick off a brand new year, I want to wish all of you a very happy and healthy new year. And of course, a heartfelt thank you for tuning in. This show continues to grow at an incredible pace as we now have listeners in more than 70 countries and thousands of plays for every episode. I'm truly grateful for your support and I'm excited for what's coming ahead in 2026. I think you're going to really love the episodes we have planned. So in our first episode of the year, we're going to be talking about something that a dentist experienced in her office after returning from a very relaxing vacation. It turns out she discovered open instrument pouches in the trash bins that were still marked red, indicating the pouch was not effectively sterilized. So what would you do in a situation like this, knowing that while you were gone, patients were being seen with unsterilized instruments? To tell us all about it is our guest, Dr. Carson Carpenter. He is a dentist and expert in OSHA, infection control compliance, HIPAA compliance, and is founder and president of Compliance Training Partners. Before we continue, I've got to give a shout out to our sponsor, NSK. These folks are the real deal. Their air and electric handpieces are not only top tier, they're the highest rated in the industry, peer-reviewed by Dental Product Shopper. Their Timex Z99L electric handpiece actually scored the first ever perfect rating. And the Timex Z990L is the most powerful handpiece on the market. So do yourself a favor. Check out everything they offer at nskdental.com and take advantage of their free trial by reaching out to your local NSK rep. I've heard this many times from many dentists. Once you start using NSK handpieces, you'll never look back. Dr. Carpenter, thanks for joining us today. Phil, thank you. Great to be back again. So as I mentioned in the introduction, Dr. Carpenter, the dentist came back from vacation and saw some things unexpectedly that I'm sure she was not very pleased to see. And that's where it all began. So tell us how this all played out. Well, you know, I think it's a great story for all of my colleagues to hear. And, you know, it's funny. I never thought about the comparison you made. But, yeah, we're kind of a true crime show here for dentistry. But I try to pick stories that really are applicable to our colleagues out there because I'd like to help them. I'd like to protect them, particularly the young doctors who maybe own their first business and don't realize where their vulnerabilities are. And this is a real cautionary tale for every doctor out there, general practitioners, every specialty. This just happened that it happened in a pediatric office. And let me tell you how this went. And a lot of times we get people who contact compliance training partners. They need maybe safety products or training products, but they think these bad things can never happen to them. But you tell me if this couldn't happen to you. So we've got a pediatric office. With an owner and an associate. Now, the owner is over the top careful with infection control. Very detailed. Does everything right. She goes on vacation. The associate's in charge. Well, she was away for about two weeks. Thought things went pretty well. You know, a couple bumps here and there, but everything went pretty well. She got back and being an owner, a detailed owner. She comes into the office the night before on a Sunday night. You know, she gets back on a Saturday. She comes in on a Sunday. How's everything in the office? She's the only one there. She looks in the waste cans and she sees a couple of sterilization pouches, you know, the disposable sterilization bags, the ones that have internal and external indicators. We all know those indicators turn from red to black, right? When they're in the autoclave. She sees a number of them torn open, thrown away that are still red. She starts checking other rooms. She starts checking the sterilization room, the disposal baskets in there. Anyway, to make a long story short, there's a whole lot of pouches that haven't turned black. So now she's panicked. What happened? What happened while I was gone? Well, I'll tell you what happened is she was gone and the inmates were running the asylum. The associate had no control over the practice. They were stuffing the autoclave full of cassettes, of instruments. Now, you can have the best autoclave in the world, but if you don't have steam circulation, you've got a problem. So they weren't following the rules of the road. It turns out, as she started to talk to some employees, this had been going on for over a week. So there were literally, possibly over 100 patients worked on. with questionably sterilized instruments. I mean, can you imagine how disastrous this is? Now, why did this happen while she was away? Don't they have an infection control coordinator still on staff or somebody who is held to account on making sure that the instruments are sterilized? There's not anybody there that does that just because the owner goes on vacation? That's the perfect question. I'm so glad you asked that because that's what I really want to talk about. is as dentists you know we we sometimes run our business um and don't delegate the things that we should don't hold people accountable like we should in a number of different areas when she had her finger on the button everything was fine but you're right phil what she didn't do is she didn't have somebody who was empowered to be in charge of infection control and osha she took on most of that responsibility she didn't have somebody who had the authority and the confidence to say to this young associate, look, Dr. X, you're not doing it right. This isn't what we're doing. This is what's going on. There wasn't a program. There wasn't training for the whole team. There wasn't written policy. This system could only work when she was on site. And, you know, it's easy for that to happen to any of us. So she was actually doing that herself as owner. or she was supervising it, or because she was there, somebody was doing it properly. And then when she left, they said, okay, the boss isn't here. Like the old saying, when the cat's away, the mice come out and play. It turns out, it appears as if there were a couple of employees who started slacking off. Another employee who noticed what was going on, didn't have the confidence to say anything. The doctor wasn't really interested. The doctor just went into work and went home. Wasn't an owner. Didn't feel that they were vested in the practice, apparently. Everything went wrong. And it all goes to show you, you've got to have training of the whole team. You have to have somebody who's held accountable. You have to have somebody who has the authority. Doesn't matter if they're an on-the-job trained assistant. If they have been trained to do sterilization properly, they have to have the authority to... to tell a hygienist when they're doing something wrong, to let a doctor know what's going on without fear of repercussions. I always say to have a safe, a culture of safety, you've got to have communication. It can't be a me doctor, you not type of environment. And that's kind of what they had there. We'll be getting right back to our guest in a second. But first, when it comes to the final step in indirect restorations, cementation is crucial. That's why thousands of top... clinicians rely on TheraseM by Bisco. This dual-cured calcium and fluoride-releasing self-adhesive resin cement is ideal for looting crowns, bridges, inlays, and onlays, with no need for a primer. TheraseM forms a strong bond directly to zirconia in most dental substrates. Its easy cleanup, convenient delivery system, high radio opacity, and continuous calcium and fluoride release make TheraseM a top choice among dental cements. For cases where you choose to apply an adhesive separately, Duolink Universal Adhesive Resin Cement is the perfect solution. Compatible with all dental materials, it works seamlessly with Bisco adhesives, such as Z' Plus and Porcelain Primer, ensuring optimal strength and adhesion. It's time to get the most out of your indirect restorations with Bisco's Advanced Dental Cements. To learn more, visit bisco.com. So how did you find out about this? reach out to you and say, Dr. Carpenter, here's what happened. What is my responsibility at this point? Because I don't know to what extent these unsterilized instruments are going to affect the patients that were treated by them or with them. We have a lot of doctors, a lot of managers across the country reach out to us because we've been through. So many OSHA inspections, public health department inspections, HIPAA inspections. And in this case, this doctor had worked with us for many years, contacted us with concerns. What should I do? I mean, you stop and think about it. In her mind, what was going through her mind was, I don't want to report this because it's going to be so destructive to my practice. Yet, I think I need to report it. Well, we worked with her. We spent some time with her and convinced her that the right thing to do, this has to be reported. We can't really tell how many people were affected. We can't say, well, it happened. It started happening two days after she left. One thing we know that an employee stated that it certainly happened within a week after she left. So we have to assume, I told her, you have to assume that the day you left, everything was done wrong. I said, describe the pouches you found. She said some had turned black. Some, the external indicator had turned black. The internal indicator had not. She said many of them, neither turned color. So in other words, we don't know what happened. I said, we've got to take everybody who was on the schedule for that two week period. They need to be informed. Can you imagine, Phil, letting those young moms savvy on social media? telling them that their child may have been worked on with instruments that weren't sterile. This is a disaster for this business. And I'll let you know in the future what the final outcome was. It's not pretty. It's very difficult. It's very stressful. It could have easily been prevented. And I want everybody out there who's listening to think about this, how you can stop this sort of thing from happening in your office. Yeah, it's a very scary scenario. spinach that's packaged in the store. You know, they do quality control, they find nothing wrong, but then a case comes back where it's reported that this one person bought this same food in a store in Florida at a Publix and got salmonella. And then they look at the batch number and they recall every single packaged food in the range of possibilities where that food could be contaminated with salmonella, and they pull it off the shelf across the country. And it cost them millions of dollars to do that, even though one person got salmonella, which was, they think, directly linked to that particular package. And it could have only been that one package, but they got to pull it all off. You're right. So the credibility of that company is tarnished, but not destroyed. Because people think, yeah, this happens. At least they have the wherewithal to know the batch numbers. They have a system, some system in place that could pull these things off the shelf for the safety of the masses. And that's a good thing. In this case, though, with a dental practice, she had to report it. I don't even know what would happen if she, I mean, if she didn't report it, I can't even imagine what would happen if somebody found out about it, that this actually happened and she did not report it. She would lose her license. Absolutely. I believe her career would be over. And think about, too, her employees would then be dealing with a gun at her head because for the employees to know that this was done and that it wasn't reported, that patients weren't informed, the public health department wasn't informed, the word's going to get out one way or another. We convinced her, you've got to report this to patients. You've got to report it to the proper agencies. And you need to show that you're trying to correct this. I said myself, I gave her my personal opinion. I said, you can talk to an employment law attorney about this one. But I said, I would consider terminating that associate. I really would, who just let this happen. Not to say that they were the only one at fault, but I felt that a head should roll because of this. This is a terrible violation. that could destroy this doctor's career. I certainly think it's appropriate to get a good PR person to craft a letter to those parents of those children that were getting services in that practice during the period of this infection control mishap. The risk of transmission of disease should be clearly laid out, that it's not high, maybe some even possibly some symptoms to look for related to blood-borne diseases that could have been passed from one patient to another. And by the way, how long a period of time passed from the time the dentist realized what was going on when she found those unsterilized pouches in the trash bin until she reached out to you and told you what happened? Right away, within two days of her returning and finding. In fact, I think she called us on a Tuesday. She arrived home on a Saturday, found out on a Sunday, called us on a Tuesday. And we've been working with her since. And one of the things we told her too is I think it's very important. that you get your written protocols and your training up to speed, that first of all, everyone is going to, it's human nature, you're going to cut someone more slack and be less judgmental if you see that they're trying to do the right thing. In other words, what programs have you implemented, doctor? This is what a board of dentistry could ask, a public health department. What programs have you implemented to make sure this could never happen in your practice again? What is your recommendation regarding the order in which she should proceed as far as reporting it? Should the parents be notified first and then the Department of Public Health second? What's your recommendation on that? I feel that the best way is first to report it to the State Department of Public Health. If they felt a need to consult with the CDC, they would, but that isn't something that the doctor or the office would need to do. So first step, Public Health Department. outlining what happened and outlining your planned response to it. In other words, how you're going to inform the patients. That would be step one. OSHA wouldn't really need to get involved because it wasn't really a hazard to employees. Although, I mean, you could read between the lines and say, well, if they were doing that, were they not working safely also? But to me, I said, let's just avoid the OSHA part of it, the worker safety part. Let's just talk about patient safety here. So public health first, patient second, and the public health department would also give them some guidance about post possible exposure monitoring that might need to be done. What about the insurance? company for liability. Would you want to report this to the insurance company at this point in time? Yeah. So that's a big thing. You'd want to report it to a malpractice carrier. So they're on board right away. So they know what's going on. Can't sweep this one under the rug. That's for sure. Yeah. So what is the, what we call in law, the statute of limitations on something like this? In other words, How long a period, in your opinion, has to pass before the office is kind of off the hook, as they say, for being responsible for that patient coming down with some sort of hepatitis B or some sort of blood-borne pathogen disease after the incident? You're right, Phil, because the chief concerns here would be hepatitis B, hepatitis C. So typically, again, we would want to follow whatever the public health department says, but typically... The CDC would say that you would want to follow them up for at least six months. And as you stated, a bloodborne disease that was contracted or that showed transmission later than that probably was from another source, not from that office. Right. So six months would be a reasonable timeframe to say that this patient has not shown any symptoms, has been tested. Now, should they be tested immediately or very soon after they're notified? the patient and then test it again six months later? That's normally the advice the public health department would give, right? To run a rapid hepatitis B, C, and HIV test on those patients. And again, as you said, it's very important to craft a proper letter because fortunately autoclaves have... how would i say over capacity over uh they they can do more than we know the odds are probably very high those instruments were okay i think that the odds of transmission of disease from this incidence are probably low but they're not zero that's the problem so you're right a properly crafted letter to reassure patients and describe the follow-up is so important here yeah i mean The only good news out of this is that it happened in a pediatric practice, which, again, it's a horrible story, a terrible situation, but at least the likelihood of HIV being in a kid, it's unlikely unless they had a blood transfusion. And hepatitis C and B, that's possible. But if you were in an adult practice, then you're looking at, I think, more risk in the transmission of certain diseases that might be more prevalent in adults than they are in children. So let's talk about, Dr. Carpenter, what happens now to that practice. You did mention that you recommend an HR change. The person who was responsible for this, the dentist who was in charge when the owner was on vacation, should be fired. What else do you foresee happening to this practice as far as the ramifications from this incident? And what other things should the practice be focusing on and doing related to this incident? First of all, I think it's very important that everything be documented. Everything, how it happened, because memory fades over time. So we asked her to carefully document this. At this point, the associate doctor is still employed there. I said, again, talk to an employment law specialist, an attorney. But I think at a minimum, a letter of reprimand, a formal letter of reprimand needs to be in that file. We need to show that you didn't just accept this. that you were very upset, that you took action, that you notified the proper authorities. I'll know more about this. Probably next time we talk, I'll know what some of the outcomes were. Let's face it, she's going to lose patients. There are going to be a certain percentage of patients that say, I just don't have confidence in that office. I'm not going to go back there. I said, you're just going to have to deal with that. But to me, more than anything, the only good thing, I guess, that would come out of this is for the people who were reaching on this podcast. Think how really easy it is to stop this. It's not rocket science. It's having training. It's having a written infection control manual. It's putting somebody in charge, holding them accountable, and creating an environment in that office where someone can say, hey, I see you didn't do that. And nobody gets mad. This is the lesson for everybody out here. It could have happened to any one of us. There's no question, Dr. Carpenter, accountability is key. needs to be responsible for those instruments. And when that dentist went away on vacation, everybody thought someone else was watching the autoclave. And it was just really unfortunate. Poor communication, poor preparation, nobody accountable. And these are all the components to a recipe for disaster. I agree this could happen to any office. Let's all be prepared for it. We really appreciate hearing your viewpoint, Dr. Carpenter. You have access to these kind of nightmarish stories, which kind of compares to true crime podcasts where we vicariously listen to these kind of bad situations that happen to other people. Makes it kind of interesting for us. Lessons learned here. And we hope that the next time we talk to you, the issue with this pediatric dentist is resolved in the best possible way. Thanks again for your time, Dr. Carpenter. Thanks for joining us. I'll look forward to seeing you next time, Phil.