Infection control breaches at Medsound Diagnostic Imaging

22 January 2021

Key points

1. Infection control breaches have been identified at a diagnostic imaging practice in Hornsby
2. Procedures may have been performed by an unregistered practitioner
3. Patients who have had certain procedures should be screened for blood borne viruses

Background

The Healthcare Complaints Commission (HCCC) and Northern Sydney Local Health District Public Health Unit (PHU) investigated this practice following a patient complaint.

The investigation found that an unregistered person was performing ultrasound procedures and writing reports, and that there were unsatisfactory infection control procedures.

The HCCC is pursuing its specific areas of concern, including the risks of potential misdiagnosis.

NSW Health has written to patients and their referring doctors, alerting them to the potential for blood borne virus infection.

Records may have been incomplete or inaccurate, so it has not been possible to clearly identify which practitioner at the practice performed procedures.

Issues

• There is potential for misdiagnosis on imaging, as an unregistered person performed procedures.
• There is potential for patient-to-patient spread of blood borne viruses and other infections, due to poor infection control practices.

What should I do?

If your patient had a procedure at Medsound between 31 January 2017 and 20 November 2020, please check if their procedure needs to be repeated.

If your patient had any of the following procedures, please discuss screening for blood borne viruses (hepatitis B, hepatitis C and HIV):

• Transvaginal/transrectalultrasound
• Orbital/periorbitalultrasound
• Ultrasound of non-intact skin
• Proceduresinvolvinginjectionsorsurgicalprocedures

Please make an assessment regarding whether your patient requires screening for other infections, dependent on the procedure they had.

Further information:

• Additional information from NSW Health can be found at https://www.health.nsw.gov.au/Infectious/alerts/Pages/diagnostic-imaging-medsound.aspx
• Additional information from the HCCC can be found at: https://www.hccc.nsw.gov.au/decisions- orders/public-statements-and-warnings/public-warning-under-s94a-of-the-health-care- complaints-act-ultrasound-services-provided-by-ms-li-shen-and-medsound-hornsby

Distributed by NSW Health.