Infection prevention and control guidelines

11. Disease surveillance and outbreak response

Critical infection prevention and control incidents

      1. Critical infection prevention and control incidents

Last revised: 18 Aug 2023

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.

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