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In this report, the Norwegian Board of Health describes the measures that the Norwegian Board of Health centrally and the Norwegian Board of Health in the counties have initiated in order to obtain an overview of the extent of the problem and the consequences of the outbreak of infection with the bacterium Pseudomonas aeruginosa, in 27 hospitals in the winter and spring of 2002.

Altogether 231 hospital patients were identified as having been infected with bacteria from infected mouth swabs used for oral care.

The conclusion of the Norwegian Board of Health is that neither health care personnel nor the health services acted in a professionally unacceptable manner by purchasing or using Dent-O-Sept mouth swabs for oral care.

However, the incident has revealed serious deficiencies within several areas of the health services, such as lack of routines for updating information about oral care, and lack of routines for purchase and use of disposable equipment.

Based on the experience from the Dent-O-Sept incident, the Norwegian Board of Health recommends that measures should be initiated in several areas to improve safety in the health services. The recommendations are presented in the report.