General Q&A

What is an IPAC lapse?

An IPAC (infection prevention and control) lapse occurs when there is a deviation from infection prevention and control standard of care and when this deviation may result in infectious disease transmission to patients or staff through exposure to blood, body fluids and/or potentially infectious lesions.

An example would be improperly cleaned reusable medical equipment that could spread viruses from one patient to another.

What happened in the IPAC lapse under investigation now at the Dr. E.E. Beduhn’s 955 Queen Street, East, Sault Ste. Marie office?

The infection prevention and control concerns are related to inadequate cleaning and sterilization of the reusable surgical instruments used for the minor surgical procedures conducted in Dr. E.E. Beduhn’s 955 Queen Street office practice.

The procedures performed in the office practice include wart removal, suture removal and removal of superficial skin lesions.

The instruments used are in a category of medical instruments that requires sterilization in order to be appropriately cleaned for reuse. The instruments in question were not sterilized. They were soaked in an enzyme detergent prior to reuse.

No procedures performed by Dr. Beduhn outside of his office practice are under investigation.

When did this occur and when did it end?

The IPAC lapse occurred in Dr. E. E. Beduhn’s office located at 955 Queen Street East, Sault Ste. Marie and was corrected on October 28, 2015.

What was the risk of exposure?

There is a risk to patients who have been exposed to inadequately cleaned and sterilized reusable surgical instruments. In this situation, essential steps were not carried out on the reusable surgical instruments used in the above-mentioned minor surgical procedures which could have led to patients being exposed to hepatitis B, hepatitis C or human immunodeficiency virus (HIV). We cannot assess the specific risk for individual patients.

Patients should be aware that they may be at risk of infection with these viruses, particularly hepatitis B and hepatitis C, and have the opportunity to get tested.

What infectious diseases are people being recommended to be tested for?

It is recommended that people be tested for hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV)

Who is at risk of exposure?

Patients of Dr. E.E. Beduhn who had certain minor surgical procedures done at 955 Queen Street, East, Sault Ste. Marie may have been exposed to hepatitis B, hepatitis C and HIV.

The procedures performed in the office practice include wart removal, suture removal and removal of superficial skin lesions. No procedures performed outside of Dr. Beduhn’s 955 Queen Street East office location are of concern.

What do I do if I am at risk of exposure?

Those patients who have had procedures at the 955 Queen Street East office location on or after April 1, 1998 are being contacted by registered mail being sent out the week of November 23, 2015.

Any patient of Dr. Beduhn who believes they had one of these procedures performed by this physician in his 955 Queen Street East office practice prior to April 1, 1998 is asked to contact the Group Health Centre at 705-759-5584 or Algoma Public Health at 705-759-8529 or 1-844-812-9183.

How many people will be receiving letters?

It is not known at this time the number of patients who have been identified as having the minor surgical procedures in the Dr. Beduhn’s office setting. We do know that 88 individuals were identified from 2008 to present. The work to identify additional patients is being completed now.

What if I don’t receive a letter?

If you think you had a minor office procedure in Dr. Beduhn’s office at 955 Queen Street East, Sault Ste. Marie (i.e. wart removal, suture removal and removal of superficial skin lesions) or are unsure, contact the Group Health Centre at 705-759-5584 or Algoma Public Health at 705-759-8529 or 1-844-812-9183.  

Are the tests confidential?

Yes

Are the tests free?

Yes

How long before I get the results?

Waiting for test results can be a stressful time. Tests are conducted by the provincial Public Health Ontario Lab.  Once they are received by the Lab, tests usually take 2-3 business days to process. The results are then sent to your physician and your physician will contact you. It may take over a week from the time you had your blood test to the time you get your results.

What if my result is positive – how will I know how I was infected?

All medical information including test results are confidential. If any of your blood test results is positive you will be notified by the physician who ordered the test. You will receive counselling and treatment as is appropriate to your test result.

If your test is ordered by a Group Health Centre physician, you will be notified whether your result is positive or negative.

In consultation with public health, additional testing can be attempted to better identify the specific “fingerprint” of a virus. However, it would be very difficult to know the source of an infection. Each situation will be carefully assessed on a case by case basis and in consultation with provincial experts.

Have any outside agencies been notified of this incident?

The College of Physicians and Surgeons of Ontario
The College of Nurses
Public Health Ontario
The Ministry of Health and Long-Term Care

When did APH find out about this?

The Group Health Centre notified Algoma Public Health on November 5, 2015 of a potential infection control breach on November 5, 2015. Upon initial notification of a potential infection control lapse, APH was assured that any breach was corrected on October 28, 2015. On November 12, GHC provided additional details to APH enabling APH to begin an investigation. APH conducted an onsite investigation on November 13, 2015 in accordance with provincial protocols.

What is public health’s role?

The role of public health is detailed in provincial protocols that specify how public health must investigate and follow up on complaints of infection prevention and control breaches and how public health must publicly disclose infection prevention and control lapses on our website.

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Date of Creation: November 23, 2015

Last Modified:      November 24, 2015