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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
While dental practices do their best to stay in OSHA’s good graces, these are some common mistakes that offices can make.
For many employers, the mere mention of the name “OSHA” is met with Bogeyman-like fear and trepidation. However, it’s important to remember that OSHA exists to protect employees. And while practices do their best to stay in OSHA’s good graces, there are some common mistakes that practices may not even realize that they’re making.
You aren’t training on bloodborne pathogens
Often, practices make the mistake of not conducting bloodborne pathogen training.
“One of the things I find is that dentists have not provided the bloodborne pathogen training that’s required every year,” says Leslie Canham, CDA, RDA, a consultant and speaker. “Every 12 months they should have a staff meeting and conduct training. But they don’t do it, and this an OSHA violation.”
“The Code of Federal Regulations (CFR) governing general industry is filled with standards that are relevant to dentistry,” says Karen Daw of Karen Daw Consulting and former clinic health and safety director for The Ohio State University College of Dentistry. “What this means is that OSHA expects the dental employer to know and follow what is outlined here. The most obvious one is the OSHA Bloodborne Pathogens (BBP) standard. Within this is mandatory annual training on the elements of the BBP standard. Common OSHA violations I see have to do with this requirement."
That training must also be specific to the practice - not some canned, generic instruction.
“Having an employer understand that even if they send someone off to an OSHA course, they still need to be reviewing their site-specific policies and procedures covering the scope of the bloodborne pathogen standard,” explains Kathy Eklund, RDH, director of occupational health and safety at The Forsyth Institute. “And that would mean some type of site-specific review of the program and training.”
So, why is this mistake so common?
According to Canham, “Dentists are busy and, as employers, may not remember everything they’re supposed to do. Sometimes they need a little assistance. For example, an accountant is going to tell the employer when to make payroll deposits and when to adjust for sick pay and things like that. Dentists don’t generally spend a lot of time paying attention to OSHA regulations because they are running a practice, providing patient care, etc., so OSHA compliance isn’t top of mind for them. They believe they are in compliance with OSHA regulations, ‘Yes I have a safe office,’ ‘Yes, we have a First Aid kit,’ and they think that that’s the end of it, but bloodborne pathogen training and reviewing the exposure control plan is mandatory every 12 months.”
Canham adds that even though the bloodborne pathogen training must occur every year, OSHA rarely makes broad, sweeping policy changes that affect the entire industry.
“OSHA doesn’t make big changes very often,” Canham says. “There’s only been a few changes that concern dentistry. In 2013, the Hazard Communication Standard was globally harmonized. So, OSHA adopted the new pictograms, label requirements and ‘material safety data sheets’ started to be called ‘safety data sheets.’ And before that, there was the Needlestick Safety and Prevention Act in 2000. It isn’t like tax law changes where they’re coming at you all the time, or HIPAA regulations. It’s pretty easy to know the basic requirements.”
The best way to stay up to date with regulatory changes, Canham says, is to be active in your professional organizations, especially the Organization for Safety, Asepsis and Prevention (OSAP).
“Every dental practice should have at least one person appointed as the infection control or OSHA coordinator and that person should be a member of OSAP,” she says. “OSAP members get newsletters and information on infection control, OSHA compliance and safety for dental settings. OSAP holds annual conferences and infection control boot camps to help dental professionals navigate the sea of regulations and stay abreast of current issues in dental infection control. In addition, members learn how to find information and resources on OSHA compliance. In 2009, when we had the swine flu pandemic, OSAP issued guidance on what we should be looking for in the dental setting and when patients and dental workers should stay home if they’re sick.”
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You don’t have an exposure plan
The aphorism, “Failing to plan is planning to fail,” is especially relevant when it comes to preparing for an accidental exposure. That is, practices must have a plan in place should an employee accidentally become exposed. And each plan must be specific to the office.
“Does the office have a written Exposure Control Plan (ECP)?” Daw asks. “Some have a fill-in-the-blank version of this; however, I’ve worked with practices that have told me they were cited because their plan was lacking. And almost all offices have no clue what this is. I recommend each office have one that is detailed and specific to their practice and then share this with the team.”
ECPs are especially important as needlesticks are concerned.
“One of the reasons I think OSHA spends any time in dentistry at all is because needlestick accidents happen,” Canham observes. “A lot of dental practices don’t realize that they need to have an emergency action plan that covers how to handle an exposure incident. The emergency action plan is a step-by-step plan that every team member is acquainted with. It’s just like CPR. You know how to perform CPR step by step, so if a patient stopped breathing, you would know exactly what to do step by step to keep them alive with chest compressions and rescue breathing.
“Just like regular CPR training, having a current and customized Exposure Incident Protocol lessens the panic and confusion should an incident occur,” she continues. “Employers and the team will know exactly what to do step by step, from First Aid to evaluating the source to what documentation is required to what health care facility to go to.”
Accidental exposures are, happily, few and far between. Practices may not immediately know what to do should something bad happen.
“Accidents happen, and because a lot of the dental practices have not conducted the OSHA bloodborne pathogen training, they have not considered what they’re going to do in the event of an exposure incident,” Canham says. “This means the employer has to spend a lot of time trying to figure out, ‘What hospital or healthcare provider do I need to send my employee to?’ ‘What kind of questions do I have to ask the patient, and do I really have to ask the patient questions about their hepatitis or HIV status?’ ‘What forms do we have to fill out?’ and ‘Do I have to call my workers’ compensation carrier?’ Meanwhile, the employee who has been stuck with the instrument or splashed to their eyes nose or mouth with blood or bodily fluid has to wait to be evaluated. Every hour that goes by increases the risk for infection transmission to occur.
“Without an exposure protocol in place panic, chaos and unnecessary delays occur,” Canham says. “It doesn’t need to take two hours from the time somebody says, ‘Ouch, I just got poked,’ to the time that they are in front of the healthcare evaluator receiving the proper consultation and potentially medication to prevent infection. It can take 10 minutes from the time the ‘ouch’ happens to the time the employee is on their way to the medical evaluator, if they have prepared an emergency action plan for exposure incidents in advance.”
Daw says information to have in the exposure control plan should include the following:
The plan doesn’t end there though. It should also include information on what to do after the initial incident.
“The office should have a detailed process for post-exposures, including evaluation and follow-up,” Daw says. “This is part of the ECP but deserves some extra attention because it is often missed and misunderstood. It should be so detailed that a non-clinician should be able to read through and understand the steps in the post-exposure protocol. Some questions to ask: Do I have an incident form? What am I going to say to the source individual? Where am I going to send them for bloodwork? What if the employee or patient decline to be tested, then what? What happens to the results? When do I send the employee back for follow-up?
“One of the ways I ensure this protocol is properly vetted is to have a front desk person with absolutely no patient contact review this document,” she continues. “If they have additional questions, I may instruct the office to address and include it in the ECP. Unfortunately, few offices have what I would consider a robust process that makes complete sense. And sometimes offices don’t realize their process is lacking until they have an exposure and find their current document is insufficient. An exposure can already be an angst-filled experience. Having an ECP will prevent an OSHA citation. Having an ECP that is detailed and thorough will alleviate the anxiety that comes with an exposure incident.”
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You’re using PPE wrong
Everyone knows just how important personal protective equipment (PPE) is, but there are a surprising number of practices using PPE incorrectly - each one a potential OSHA violation.
“One of the biggest issues with PPE is with protective eyewear,” Canham says. “Protective eyewear is not being utilized by the clinical team members and sometimes not even by the dentists themselves. And what I mean by protective eyewear is the American National Standards Institute (ANSI) rated protective eyewear. Regular prescription glasses do not meet this standard as protective eyewear.
“Today, many people wear the large-style of glasses, where they almost look like the Elvis Costello glasses with the big, bulky frames and huge lenses,” she continues. “I think people are feeling confident that those large lenses are protective, but it’s not enough. Eye injuries still occur because they don’t have side shields and a brow guard. While the lenses may be thick enough, it doesn’t necessarily protect them from what comes in underneath the lenses, between the cheekbones and the bottom rim of their glasses. A mistake that I find is a lot of employers are allowing their employees to wear prescription glasses that are not protective eyewear don’t provide enough protection against splashes and spatters that occur.”
Clinicians must also be cognizant of mistakenly wearing scrub tops and considering them to be barrier attire.
“If a clinician becomes warm or hot with a lab coat on, they may take it off, thinking that a scrub top is appropriate barrier attire,” Eklund says. “A scrub top really wouldn’t meet the requirements for barrier attire in dentistry. The scrub has short sleeves and must be removed by inverting over the head. Barrier attire should be able to be removed by unbuttoning, unzipping, untying, or unclasping from the front or the back, never over the head.”
Barrier attire provides specific protections that simple scrub tops don’t.
“Inverting the scrub top over your head to remove poses a risk of contamination exposure to the nose, mouth and eyes,” Eklund explains. “Plus, in looking at the type of exposure you have in dentistry to spatter, you want something covering your skin and underclothing. The design should be long sleeve, high neck, longer length, and needs to be removed from the front or the back.”
Facemasks are another routinely misused item of PPE.
“The surgical facemask has to be worn over the nose and over the mouth,” Canham says. “Dental providers who are wearing their mask below the nose are not protected, and if they are wearing it below their chin, they are actually spreading more contamination to their neck and chin area. The mask is considered to be a single-use, disposable item. In most common dental settings, it is to protect the employee or protect the wearer. It’s not really to protect the patient unless you are performing invasive surgical procedures. Then the mask plays a part in protecting the patient from what the healthcare provider might be exhaling. If the mask is not being worn properly it’s not doing its job as a filter.”
It isn’t just how masks are worn that must be taken into consideration. Clinicians must also understand that masks are used to filter particles and bacteria and provide protection from moisture for the wearer.
“If you have a high-moisture environment, like when a high-speed handpiece or an ultrasonic scaler is going, then you’re exposed to more moisture and you should have a higher-level mask,” Canham says.
Ultimately, OSHA exists to protect employees, not punish employers. By looking out for these common missteps, you’re not only protecting your practice from running afoul of OSHA but also protecting your employees from harm.
Canham is offering a complimentary copy of an Exposure Incident Protocol by sending an email to Office@LeslieCanham.com.