After SGH reported the cluster to the Ministry of Health
(MOH), an independent committee was created and conducted a two-month investigation into the incident.
The committee pointed to a number of factors included staff lapses and gaps in work processes as causing the resulting disease outbreak.
The final report highlighted improper staff procedures such as the misuse of clean rooms or failure to properly sterilise equipment as possible causes of the cluster.
This incident has highlighted the serious health ramifications for both staff and patients of poor HR practices in the healthcare sector, and the continued importance of solid workplace health and safety practices across the board.
Committee member, Lim Seng Gee, said that while staff seemed to follow proper workplace procedures during the investigation, improvement may have been made as a result of the hep C cluster.
“When we interviewed them, the practices seemed to be good, but of course that may not have been the case at the time when the outbreak was occurring. It's very difficult to know exactly what went on.”
In addition to improper workplace processes, the committee also found the relocation of the renal ward from Ward 64A to Ward 67 in April could also have contributed to the outbreak.
Ward 64A had a more compact layout with a preparation room in its centre. On the other hand, staff in Ward 67 had to walk further between the patients’ beds and the area for preparing medicine.
“The workflow process issues opened up potential for modified infection control practices among ward staff,” the committee reported.
As the physical office layout can change employee behaviour, HR should remember to take this into account when developing and upgrading occupational health and safety policies for the workplace.
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Inefficient work processes have been highlighted as a contributing factor to the outbreak of hepatitis C which occurred in Singapore General Hospital (SGH) from 17 April to 15 July this year.