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Infection Prevention and Control (IPAC) Standard

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All OHP staff are responsible for complying with appropriate IPAC practices and for taking action where inappropriate practices are occurring (i.e., those that are out of line with infection prevention and control standards). Everyone has a responsibility to monitor their own practice as well as the practice of the other health care providers working in the OHP to ensure patient safety.


  1. Medical Directors must ensure appropriate infection prevention and control practices are occurring within the OHP, including compliance with all applicable legislation and regulations1 and any directives or guidelines issued by Public Health Ontario or the Ministry of Health, as well as with Public Health Ontario’s Infection Prevention and Control for Clinical Office Practice2.3
  2. In particular, Medical Directors must ensure that the following is occurring within the OHP:
    1. Adherence to Routine Practices4 and Additional Precautions5;
    2. Compliance with safe medication practices;6
    3. Maintenance of a clean and safe health care environment with environmental cleaning and disinfection appropriate to the clinical setting performed on a routine and consistent basis;
      1. Areas where surgery and invasive procedures are performed are cleaned and disinfected according to standards set by the Operating Room Nurses Association of Canada (ORNAC);7
    4. Reprocessing of medical equipment is done in accordance with the manufacturer’s instructions and/or accepted standards and reflects the intended use of the equipment or device and the potential risk of infection involved in the use of the equipment or device8;
    5. Accepted standards of handling regulated waste are adhered to9.
  3. Medical Directors must ensure the following is in place to support appropriate IPAC practices:
    1. well documented policies and procedures which are periodically reviewed by staff;
    2. all staff are properly trained and are provided with regular education and support to assist with consistent implementation of appropriate IPAC practices;
    3. responsibility for specific obligations are clearly defined in writing and understood by all staff; and
    4. mechanisms are in place for ensuring a healthy workplace, appropriate staff immunizations and written protocols for exposure to infectious diseases, including a blood-borne pathogen exposure protocol.10
  4. Where substandard IPAC practices are occurring, all staff must take appropriate action, including advising the Medical Director, addressing the issue with the individual responsible for the infraction, and/or reporting to the relevant Medical Officer of Health, where required11.


1. This includes, for example, the Occupational Health and Safety Act (hereinafter OHSA), as well as the Needle Safety Regulation (O. Reg 474/07) under the OHSA, and the Workplace Hazardous Materials Information System (WHMIS).

2. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Infection Prevention and Control for Clinical Office Practice. 1st Revision. Toronto, ON: Queen’s Printer for Ontario; April 2015.

3. A summary of mandatory practices and best practice recommendations for clinical office practice is set out on page 72 of Infection Prevention and Control for Clinical Office Practice.

4. Routine Practices are based on the premise that all patients are potentially infectious, even when asymptomatic, and that the same standards of practice must be used routinely with all patients to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or soiled items and to prevent the spread of microorganisms.

5. “Additional Precautions” refer to IPAC interventions (e.g., barrier equipment, accommodation, additional environmental controls) to be used in addition to Routine Practices to protect staff and patients and interrupt transmission of certain infectious agents that are suspected or identified in a patient.

6. For additional information see Appendix H: Checklist for Safe Medication Practices set out in Infection Prevention and Control for Clinical Office Practice.

7. For more information about environmental cleaning in surgical areas refer to the Operating Room Nurses Association of Canada (ORNAC) standards, which are now under the auspices of the Canadian Standards Association.

8. For additional information see Appendix I: Recommended Minimum Cleaning and Disinfection Level and Frequency for Medical Equipment set out in Infection Prevention and Control for Clinical Office Practice.

9. “Regulated Waste” means: a) liquid or semi-liquid or other potential infectious material; b) contaminated items that would release blood or other potential infectious materials in a liquid or semi-liquid state are compressed; c) items that contain dried blood or other potential infectious materials and are capable of releasing these materials during handling; d) contaminated sharps; e) pathological and microbiological wastes containing blood or other potentially infectious materials.

10. For additional information see Appendix J: Checklist for Office Infection Prevention and Control set out in Infection Prevention and Control for Clinical Office Practice.

11. Please see CPSO’s Mandatory and Permissive Reporting policy for more information on the specific instances that require reporting to the Medical Officer of Health.