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Infection prevention and control guidelines

11. Disease surveillance and outbreak response

Critical infection prevention and control incidents

      1. Critical infection prevention and control incidents

Critical infection prevention and control incidents

In the event of a critical incident (eg a failure of sterilisation or disinfection, or an exposure to blood or body substances), the local public health unit must be advised immediately.

If there has been a breakdown in an infection prevention and control procedure or protocol in the practice, a ‘lookback’ investigation may be necessary to identify, trace, recall, counsel and test patients or healthcare workers who may have been exposed to an infection (usually a blood-borne virus).

Monitoring of critical incidents and other sentinel events is an important part of surveillance. A structured process should be undertaken to identify the problem and contributing factors (eg a root cause analysis), explore and identify risk reduction strategies, and implement solutions.

Ethical and legal considerations apply to the conduct of lookback investigations.