About the AuthorSheila Dunn, DA, MT (ASCP), holds a doctoral degree in clinical laboratory science from the Catholic

University of America in Washington, DC. She has helped thousands of outpatient medical facilities comply

with federal regulations such as CLIA and OSHA through her presentations at a nationwide seminar series.

She has written more than 150 articles about regulatory issues and healthcare delivery systems and serves

as an advisor to numerous companies. 10I

©2005–2010. HCPro, Inc. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user’s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.

HCPro, Inc.P.O. Box 1168

Marblehead, MA 01945Tel: 800/650-6787Fax: 800/639-8511

www.hcmarketplace.com

OSHAPROGRAMMANUALfor Dental Facilities

OSHA Program Manual for Dental Facilities is published by HCPro, Inc.

Copyright © 2010 HCPro, Inc.

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-60146-744-7

No part of this publication may be reproduced, in any form or by any means, without ¬prior written consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have received an unauthorized copy.

HCPro, Inc., provides information resources for the healthcare industry.

HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

Sheila Dunn, DA, MT (ASCP), AuthorDavid A. LaHoda, Managing EditorMichael Briddon, Executive EditorEmily Sheahan, Group PublisherMike Mirabello, Senior Graphic ArtistMatt Sharpe, Production SupervisorJean St. Pierre, Senior Director of Operations

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.

Arrangements can be made for quantity discounts. For more information, contact:

HCPro, Inc.P.O. Box 1168Marblehead, MA 01945Telephone: 800/650-6787 or 781/639-1872Fax: 781/639-2982E-mail: customerservice@hcpro.com

Visit HCPro at its World Wide Web sites:www.hcpro.com, www.hcmarketplace.com

09/201021808

ix

IntroductionImportant Information About the Use of This Program ............................. iHow to Customize this Program .................................................................. iiWhat Is Included in This Program ............................................................... vi

TAB 1: OSHA Jurisdictions & InspectionsA Quick Look at OSHA .................................................................................. 1-1

States with OSHA-Approved Plans ......................................................................................1-1OSHA Consultative Services Division ..................................................................................1-2OSHA’s Jurisdiction ..............................................................................................................1-2OSHA’s General Duty Clause ..............................................................................................1-2

Employee or Employer? ............................................................................... 1-3Employer Responsibilities Under OSHA ..............................................................................1-4

Overview of OSHA Standards ...................................................................... 1-5OSHA Inspections ......................................................................................... 1-5

Employee Complaints ..........................................................................................................1-5If an On-site OSHA Inspection Occurs .................................................................................1-6During the Inspection ...........................................................................................................1-7What OSHA Inspectors May Ask Employees .......................................................................1-7The Typical OSHA Inspection ...............................................................................................1-8The Closing Conference .......................................................................................................1-8

OSHA Sanctions ............................................................................................ 1-10Whistleblower Protection ............................................................................. 1-12Students and Volunteers .............................................................................. 1-13

OSHA PROGRAM MANUAL

Contents

Front Pocket OSHA Poster 3165: IT’S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self-Adhesive Labels CD-ROM (MS Word for Windows 2000) with Master Record Forms (Tab 8) from this Manual

for Customization.

Page

x

Contents

TAB 2: Injury & Illness Prevention ProgramKey Contacts for the OSHA Safety Program ........................................................................2-2Location of the OSHA Safety Program .................................................................................2-2

Duties of the OSHA Safety Officer ............................................................... 2-2Accident/Incident Investigation & Reporting Procedure ........................... 2-3

Definition of an Accident and/or Incident ..............................................................................2-4When to Investigate an Accident/Incident ............................................................................2-4How to Document an Accident/Incident................................................................................2-4Recording Accidents or Injuries for OSHA............................................................................2-4Correcting Unsafe Conditions ..............................................................................................2-4

Recordkeeping Requirements ..................................................................... 2-5Equipment & Facility Records ..............................................................................................2-5Bloodborne Pathogens Records ..........................................................................................2-5Hazard Communication Records .........................................................................................2-5TB Records ..........................................................................................................................2-5Employee Medical Records ..................................................................................................2-6Evaluating Exposure Incidents .............................................................................................2-6

Workplace Hazard Analysis ......................................................................... 2-7Employee Training ........................................................................................ 2-8

Checklist for an Effective Safety Training Session ...............................................................2-8Interactive Safety Training Exercises ...................................................................................2-9

General Safety .............................................................................................................2-9Fire Safety ....................................................................................................................2-9Bloodborne Pathogens Safety .....................................................................................2-10Chemical Safety ...........................................................................................................2-10TB Safety .....................................................................................................................2-10

Annual Employee Retraining ....................................................................... 2-10Bloodborne Pathogens Annual Training Contents................................................................2-11Respiratory Protection Annual Training Contents.................................................................2-12Hazard Communication Annual Training Contents...............................................................2-12

New Employee Orientation ........................................................................... 2-12Documenting Employee Training ................................................................ 2-12

OSHA Yearly Retraining .......................................................................................................2-13

Practical Ideas for Administering the OSHA Safety Program ................... 2-17Organizing OSHA Compliance Duties ......................................................... 2-17

Weekly Facility Review Checklist .........................................................................................2-19Monthly Facility Review Checklist ........................................................................................2-20Annual Facility Review Checklist ..........................................................................................2-21Annual OSHA Safety Program (Exposure Control Plan) Review Form ...............................2-24

xi

Contents

TAB 3: General Facility SafetyKeeping Employees Safe ............................................................................. 3-1

Important Phone Numbers & Contacts.................................................................................3-1Emergency Phone List .........................................................................................................3-2

Fire Safety ...................................................................................................... 3-3Automatic Sprinkler Systems ...............................................................................................3-3Fire Alarms ...........................................................................................................................3-3Fire Procedures: Immediate Actions ....................................................................................3-3Building Evacuation ..............................................................................................................3-4Fire Extinguishers .................................................................................................................3-4

Purchase the Right Extinguisher ..................................................................................3-5How Many Fire Extinguishers to Have & Where to Put Them .....................................3-6How to Use a Fire Extinguisher: The “PASS” Technique .............................................3-6When to Extinguish Fires with a Portable Fire Extinguisher ........................................3-6

Fire extinguisher supplement ...................................................................... SupplementWhen NOT to Extinguish Fires and to Evacuate ..........................................................3-7Fire Extinguisher Inspections .......................................................................................3-7Fire Extinguisher Maintenance .....................................................................................3-7

Fire Drills ..............................................................................................................................3-7

Electrical Safety ............................................................................................ 3-8Physical Characteristics of a Safe Dental Facility ..................................... 3-8

Air Quality .............................................................................................................................3-8Mold .............................................................................................................................3-9

Mold Remediation ................................................................................................3-10Aisles ....................................................................................................................................3-11Emergency Lighting ..............................................................................................................3-11Employee Dress Code .........................................................................................................3-11Exits, Means of Egress .........................................................................................................3-11Exit Doors .............................................................................................................................3-12Exit Signs .............................................................................................................................3-12Floors ...................................................................................................................................3-13Lighting .................................................................................................................................3-13Noise ....................................................................................................................................3-13Restricted Access Areas .......................................................................................................3-14Sinks .....................................................................................................................................3-14Storage .................................................................................................................................3-14Dental Lab Equipment ..........................................................................................................3-14Air Compressors ..................................................................................................................3-14

Systems Failure ............................................................................................. 3-15Evacuation Plan ............................................................................................ 3-15

Evacuation Procedures ........................................................................................................3-16Evacuation Route .................................................................................................................3-17

xii

Contents

Emergency Preparedness Supplies ............................................................ 3-19Emergency Action Procedures .................................................................... 3-19

Bioterrorism: Suspicious Letters or Packages ......................................................................3-19What is a “Suspicious Package”? ................................................................................3-19

Bomb Threat .........................................................................................................................3-20If You Discover a Bomb or a Suspicious Item ..............................................................3-20Explosion ......................................................................................................................3-20

Civil Disturbance ..................................................................................................................3-21Earthquake ...........................................................................................................................3-21

If a Tremor Occurs when You Are Inside ......................................................................3-21After the Tremor Is Over ...............................................................................................3-21

Severe Weather ...................................................................................................................3-22Flood ............................................................................................................................3-22Hurricane ......................................................................................................................3-22Severe Thunderstorm or Tornado Warning ..................................................................3-22Tornado Safety Tips .....................................................................................................3-23Severe Thunderstorm or Tornado Watch .....................................................................3-23Toxic External Atmosphere ...........................................................................................3-23

Violence ................................................................................................................................3-23Violence Prevention Plan Introduction .........................................................................3-23Overview of Violence Prevention Plan Components ....................................................3-23

Part 1 ...................................................................................................................3-24Part 2 ...................................................................................................................3-30

More Sources for Prevention of Workplace Violence ...................................................3-31

First Aid .......................................................................................................... 3-31First Aid Kit ...........................................................................................................................3-31Basic First Aid for Common Emergencies ............................................................................3-32Crash Kit/Cart Components ................................................................................................3-34

Drug-Free Workplace Program .................................................................... 3-36Service Animals ............................................................................................. 3-41Holiday Decorations ..................................................................................... 3-43

Sample Checklist: Spot Check Your Facility’s Holiday Decorations .....................................3-43

Safe Decorations and Displays Policy ........................................................ 3-45

TAB 4: Ergonomics in the Dental WorkplaceA Quick Look at Ergonomics ....................................................................... 4-1Identifying Ergonomic Stressors ................................................................. 4-2Common Musculoskeletal Disorders .......................................................... 4-3

Repetitive Stress Injuries/Wrist Injuries ................................................................................4-3Eye Strain .............................................................................................................................4-4

Why Prevent CVS ........................................................................................................4-5

xiii

Contents

Symptoms of CVS ........................................................................................................4-5Other Suggestions for Relieving Eye Strain .................................................................4-6

Back Injuries .........................................................................................................................4-6Fatigue .................................................................................................................................4-6

Selecting Ergonomically Sound Equipment ............................................... 4-7Ergonomically Sound Work Strategies ....................................................... 4-8Ergonomics Resources ................................................................................ 4-8

TAB 5: Bloodborne Pathogens Exposure Control PlanExposure Control Plan Introduction ........................................................... 5-1Overview of Bloodborne Pathogen Standard Components ...................... 5-2A Quick Look at Occupational Exposure .................................................... 5-3Key Provisions and Effective Dates ............................................................ 5-3Universal Precautions .................................................................................. 5-3

Other Potentially Infectious Materials (OPIM) ......................................................................5-4Implementing Universal Precautions ....................................................................................5-4

Bloodborne Pathogens ................................................................................. 5-5Epidemiology of Bloodborne Pathogens ..............................................................................5-5Update on AIDS in the Workplace ........................................................................................5-8Transmission of Bloodborne Pathogens ..............................................................................5-9

Exposure Determination ............................................................................... 5-9Personnel Who Are Occupationally Exposed .......................................................................5-9

Exposure Prone Procedures ........................................................................................5-9Bloodborne Pathogens Exposure Determination List #1 (Form 8) .......................................5-11Other Personnel Who Could Potentially Be Occupationally Exposed ..................................5-12Employees Who Are Not Occupationally Exposed...............................................................5-12Bloodborne Pathogens Exposure Determination List #2 (Form 9) .......................................5-13

Restricted Access Areas .............................................................................. 5-14Engineering/Work Practice Controls ........................................................... 5-14

Biohazard Labels ..................................................................................................................5-15Handwashing ........................................................................................................................5-15

When to Wash Hands ..................................................................................................5-16How to Wash Hands ....................................................................................................5-16Artificial Nails ................................................................................................................5-17

Sharps Safety .......................................................................................................................5-17What to Look for in Safety Devices ..............................................................................5-18Sharps Evaluation Procedure ......................................................................................5-18Use of Non-Safe Sharps ..............................................................................................5-19

Sharps Containers ................................................................................................................5-20Sharps Container Maintenance ....................................................................................5-21Sharps Container Disposal Procedure .........................................................................5-21

Servicing or Shipping Contaminated Equipment ..................................................................5-21Decontaminating Work and Touch Surfaces ........................................................................5-21Sample Housekeeping Schedule .........................................................................................5-23

xiv

Contents

Spill Containment Plan ................................................................................. 5-24Spill Cleanup Procedures .....................................................................................................5-24Spills that Contain Broken Glass or Sharp Objects ..............................................................5-24

Instrument Sterilization and Disinfection ................................................... 5-25Transport and Precleaning ...................................................................................................5-25When to Sterilize ..................................................................................................................5-25

Sterilization ...................................................................................................................5-26Quality Checks for Sterilization ....................................................................................5-26

High-Level Disinfection ................................................................................ 5-27Keeping Employees Safe during Instrument Disinfection ....................................................5-27Sterilants/High-Level Disinfectants .......................................................................................5-28

Decontamination ........................................................................................... 5-29Decontaminating Semi-Critical Equipment ...........................................................................5-29Decontaminating Non-Critical Patient Care Equipment .......................................................5-29Decontaminating Personal Protective Equipment (PPE) .....................................................5-29

Eyewashes ..................................................................................................... 5-30Number & Placement of Eyewash Stations..........................................................................5-30Eyewash Maintenance .........................................................................................................5-31

Eyewash Checks ..........................................................................................................5-31

Waste Disposal .............................................................................................. 5-31Biomedical Waste Disposal ..................................................................................................5-31Hazardous Waste Disposal ..................................................................................................5-32Waste Handling & Storage ...................................................................................................5-33Laundry ................................................................................................................................5-33

Personal Protective Clothing & Equipment ................................................ 5-34Gloves ..................................................................................................................................5-35

When to Wear Gloves ..................................................................................................5-36How to Wear Gloves ....................................................................................................5-36Latex Allergy .................................................................................................................5-37Preventing Allergic Reactions ......................................................................................5-38

Face Protection ....................................................................................................................5-38Body Protection ....................................................................................................................5-38Emergency Resuscitation Equipment ..................................................................................5-40

Hepatitis B Vaccine ....................................................................................... 5-40Safety of the Hepatitis B Vaccine .........................................................................................5-41Documenting Employee Hepatitis B Vaccinations ................................................................5-41Titering Employees after the Hepatitis B Vaccination ...........................................................5-42

How to Determine Employee Immunity ........................................................................5-42Testing Employees Vaccinated before the Titer Requirement ......................................5-43

Types of Hepatitis B Tests ............................................................................ 5-43Interpreting Hepatitis B Test Results ....................................................................................5-44

New Employee Hepatitis B Virus (HBV) Vaccination Flow Chart .............. Supplement

Post-exposure Evaluation & Follow-up ...................................................... 5-45What Is an Exposure? ..........................................................................................................5-45

xv

Contents

What to Do after an Occupational Exposure ........................................................................5-45When to get Expert Consultation for HIV Post-exposure Prophylaxis .........................5-50

Confidentiality of Post-exposure Procedures .......................................................................5-50Employee Counseling/Precautions .....................................................................................5-51

Occupational Exposure Management Resources ...................................... 5-51Accident Report/Sharps Injury (Form 11) .................................................... 5-52Post-exposure Checklist (Form 14) ............................................................. 5-54Post-exposure Medical Evaluation Declination Form (Form 15) ............... 5-55Injection Safety .............................................................................................. 5-57

Information for Providers ......................................................................................................5-57Unsafe Injection Practices and Disease Transmission.........................................................5-58

Frequently Asked Questions: Injection Safety FAQs for Providers ......... 5-58Overview ..............................................................................................................................5-58Injection Procedures .............................................................................................................5-59Resources ............................................................................................................................5-62

Infection-Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens ..................... Supplement

Bloodborne Pathogens Resources ............................................................. 5-63Bloodborne Pathogens Violations in Dental Practices ............................. 5-64

TAB 6: Hazardous Chemical & Radiation SafetyA Quick Look at HazCom .............................................................................. 6-1

Determining Which Chemicals Are Hazardous ....................................................................6-1Routes of Exposure to Hazardous Substances....................................................................6-2

Material Safety Data Sheets ......................................................................... 6-2Examples of Substances Requiring MSDS ..........................................................................6-2Substances Not Requiring MSDS ........................................................................................6-3MSDS Flowchart Determination ...........................................................................................6-4Information Required on MSDS ...........................................................................................6-4How to Get MSDS ................................................................................................................6-5Where to Keep MSDS ..........................................................................................................6-5HazCom Recordkeeping ......................................................................................................6-5

Classification of Hazardous Substances .................................................... 6-5Flammable & Combustible Liquids .......................................................................................6-6

Storage of Hazardous Substances .............................................................. 6-6Special Hazard Communication Requirements for California ..............................................6-7

Hazardous Chemicals with Permissible Exposure Limits (PEL) .............. 6-8Avoiding Overexposure to Hazardous Chemicals ................................................................6-8

Beryllium-Containing Alloys ..........................................................................................6-8Glutaraldehyde .............................................................................................................6-9Sterilant Safety Supplement .........................................................................................SupplementGlutaraldehyde Spills ...................................................................................................6-11

xvi

Contents

Testing the Potency of Glutaraldehyde ........................................................................6-11Disposing of Glutaraldehyde ........................................................................................6-11Mercury ........................................................................................................................6-12Nitrous Oxide ...............................................................................................................6-12Silica .............................................................................................................................6-13

Monitoring Employees for Exposure ....................................................................................6-13

Labeling Hazardous Substances ................................................................. 6-14NFPA Label System .............................................................................................................6-14

Safety Tips for Working with Hazardous Substances ............................... 6-14Chemical Spill Cleanup Procedures .....................................................................................6-15Chemical Exposure to Skin ..................................................................................................6-15

Medical Consultation & Injury Evaluation .................................................. 6-15Hazardous Chemical Waste Packaging & Disposal ................................... 6-16Special Precuations for Dental Labs ........................................................... 6-17

Silicosis ................................................................................................................................6-17Tasks in a Dental Lab that Can Cause Silica Exposure ...............................................6-17Controlling Exposure to Silica ......................................................................................6-17Other Potential Health Hazards Associated with Working in a Dental Lab ..................6-18

Allergic Reactions to Dental Products ..................................................................................6-18

Gas Cylinder Safety ...................................................................................... 6-19Electrosurgical Safety (Lasers) .................................................................. 6-20

Safe Laser Practices ............................................................................................................6-21

Radiation Safety Policies ............................................................................. 6-21Radiation Safety in Dental Practice ......................................................................................6-22Protecting Staff from Unnecessary Radiation Exposure ......................................................6-22Ionizing Radiation Exposure Limits ......................................................................................6-23Limiting Exposure to Women of Childbearing Age ...............................................................6-23Employee Training ................................................................................................................6-23Miscellaneous Ways to Minimize Radiation Exposure .........................................................6-24Regulation of the Medical Use of Nuclear By-Products .......................................................6-24Nuclear Regulatory Commission ..........................................................................................6-24

TAB 7: Infection Control A Quick Look At TB ....................................................................................... 7-1

TB Transmission ...................................................................................................................7-1Risk Factors for Developing Active TB .................................................................................7-2

TB Exposure Control Plan Policy ................................................................ 7-2Overview: How to Protect Staff from Contracting TB at Work ..............................................7-3TB Risk Assessment ............................................................................................................7-3

TB Risk Assessment Results Form (Form 21) .............................................................7-5Early Identification of Patients with Active TB ......................................................................7-6

Symptoms of TB ...........................................................................................................7-6

xvii

Contents

Managing Patients with Suspected or Confirmed TB ...........................................................7-9TB Isolation Procedures for Cough Inducing & Aerosol-Generating Procedures.........7-9Respiratory Protection for Dental Workers: N-95 Respirators .....................................7-9

Seal Checking N-95 Respirators ..........................................................................7-10Employee TB Skin Testing (TST) .........................................................................................7-10

Baseline Employee TST: The Two-Step PPD Skin Test ...............................................7-11Two-Step TST Interpretation ................................................................................7-11

False Positive/False Negative TB Tests .......................................................................7-11Workers Who Have Had BCG Vaccination ..........................................................7-12Periodic Retesting of Employees .........................................................................7-12Recording TST Results ........................................................................................7-12

TST Record (Form 22) .................................................................................................7-13TB Skin Test Declination (Form 23) .............................................................................7-14

Evaluation & Management of Healthcare Employees Exposed to TB .................................7-15Employees with Symptoms of TB ................................................................................7-15Employees Who Have Been Exposed to a Known TB Patient ....................................7-15Positive Employee Skin Tests & Skin Test Conversions ..............................................7-15TB Exposure Log (Form 24) .........................................................................................7-16

Decontaminating Patient Care Area and Equipment ............................................................7-17Employee Training ................................................................................................................7-17

Pandemic Influenza Plan .............................................................................. 7-18Pre-pandemic Influenza Planning ........................................................................................7-18Once A Pandemic Is Announced ..........................................................................................7-21OSHA Enforcement Procedures for 2009 H1N1 ..................................................................7-23

Identifying Very High and High Exposure Risks ...........................................................7-23Dealing with N-95 Respirator Shortages ......................................................................7-24Prioritize Your Facility’s Use of N-95 Respirators .........................................................7-24Documentation .............................................................................................................7-25

Pandemic Influenza Resources............................................................................................7-26

MRSA Prevention and Control ..................................................................... 7-26MRSA Transmission .............................................................................................................7-27Patient Precautions ..............................................................................................................7-27

Hand Hygiene ..............................................................................................................7-28Contact Precautions .....................................................................................................7-28

Environmental Cleaning .......................................................................................................7-29Infected Employees ..............................................................................................................7-30MRSA Resources .................................................................................................................7-31Healthcare Worker Vaccination Recommendations 2009 ....................................................7-32

MMWR: Guidelines for Infection Control in Dental Healthcare Settings... 1-66

TAB 8: Master Record FormsGeneral Equipment and Facility Records

Safety Report .......................................................................................................................Form 1Autoclave Log .......................................................................................................................Form 2Eyewash Weekly Check Log ................................................................................................Form 2-AAnnual OSHA Safety Program Review ................................................................................Form 3

xviii

Contents

Weekly Facility Review Checklist .........................................................................................Form 4-AMonthly Facility Review Checklist ........................................................................................Form 4-BAnnual Facility Review Checklist ..........................................................................................Form 5Fire Drill Evaluation Form.....................................................................................................Form 5-AEmployee Fire Drill Participation Sign-up Sheet..................................................................Form 5-BHousekeeping Schedule ......................................................................................................Form 6

Bloodborne Pathogens RecordsBloodborne Pathogens Exposure Determination List #1......................................................Form 7Bloodborne Pathogens Exposure Determination List #2......................................................Form 8Bloodborne Pathogens PPE Compliance Checklist .............................................................Form 8-ASafety Needle/Syringe Evaluation Form ..............................................................................Form 9Sharps Disposal Container Locations ..................................................................................Form 9-ABloodborne Pathogens Compliance Checklist: ECP, Training, and Records..................... ..Form 9-BSharps Evaluation Results Form ..........................................................................................Form 10

Bloodborne Pathogens Employee Medical RecordsAccident Report/Sharps Injury Log.......................................................................................Form 11Sharps Injury Log .................................................................................................................Form 11-AHBV Vaccination Declination Form ......................................................................................Form 12HBV Employee Vaccination Form ........................................................................................Form 13Post Exposure Checklist ......................................................................................................Form 14Post Exposure Medical Evaluation Declination Form...........................................................Form 15Source Patient Testing Consent Form ..................................................................................Form 16

Hazard Communication Records Hazardous Substances List ..................................................................................................Form 17Sample MSDS Request Letter .............................................................................................Form 18

Training RecordsNew Employee OSHA Orientation Checklist ........................................................................Form 19Annual Employee Training Record .......................................................................................Form 20Respiratory Protection Training Record ...............................................................................Form 20-A

TB / Infection Control RecordsTB Risk Assessment Results Form ......................................................................................Form 21TST Record ..........................................................................................................................Form 22TB Skin Test Declination ......................................................................................................Form 23 TB Exposure Log ..................................................................................................................Form 24Influenza Vaccine Log ..........................................................................................................Form 25Influenza Vaccine Declination Form ....................................................................................Form 25-ADeclination of H1N1 Influenza Vaccination ..........................................................................Form 25-B

xix

Contents

TAB 9: OSHA Regulations & Key ContactsOSHA Regulations

Bloodborne Pathogens Standard .........................................................................................9-1Amended Bloodborne Pathogens Standard (Sharps Safety) ...............................................9-13Hazard Communication Standard ........................................................................................9-14Exit Routes, Emergency Action Plans, and Fire Prevention Plans.......................................9-29Ionizing Radiation .................................................................................................................9-34Other OSHA Standards for Dental Facilities ........................................................................9-42

Additional OSHA ResourcesSuggested Work Restriction for Employees ........................................................................9-43

Key ContactsOSHA Consultative Services State Directory .......................................................................9-47Directory of States with Approved OSHA Plans ...................................................................9-50

Acronyms used in the OSHA Program Manual .......................................... 9-52

TAB 2: INJURY & ILLNESS PREVENTION PROGRAM

Contents

Key Contacts for the OSHA Safety Program ..........................................................................2-2Location of the OSHA Safety Program ...................................................................................2-2

Duties of the OSHA Safety Officer .................................................................. 2-2Accident/Incident Investigation & Reporting Procedure .............................. 2-3

Definition of an Accident and/or Incident ................................................................................2-4When to Investigate an Accident/Incident ...............................................................................2-4How to Document an Accident/Incident ..................................................................................2-4Recording Accidents or Injuries for OSHA ..............................................................................2-4Correcting Unsafe Conditions .................................................................................................2-4

Recordkeeping Requirements ........................................................................ 2-5Equipment & Facility Records .................................................................................................2-5Bloodborne Pathogens Records .............................................................................................2-5Hazard Communication Records ............................................................................................2-5TB Records .............................................................................................................................2-5Employee Medical Records ....................................................................................................2-6Evaluating Exposure Incidents ...............................................................................................2-6

Workplace Hazard Analysis ............................................................................. 2-7Employee Training ........................................................................................... 2-8

Checklist for an Effective Safety Training Session .................................................................2-8Interactive Safety Training Exercises ......................................................................................2-9

General Safety ................................................................................................................2-9Fire Safety .......................................................................................................................2-9Bloodborne Pathogens Safety ........................................................................................2-10Chemical Safety ..............................................................................................................2-10TB Safety ........................................................................................................................2-10

Annual Employee Retraining .......................................................................... 2-10Bloodborne Pathogens Annual Training Contents ..................................................................2-11Respiraotry Protection Annual Training Contents ...................................................................2-12Hazard Communication Annual Training Contents .................................................................2-12

New Employee Orientation .............................................................................. 2-12

Page

Documenting Employee Training ................................................................... 2-12OSHA Yearly Retraining ..........................................................................................................2-13

Practical Ideas for Administering the OSHA Safety Program ...................... 2-17Organizing OSHA Compliance Duties ............................................................ 2-17

Weekly Facility Review Checklist ...........................................................................................2-19Monthly Facility Review Checklist ...........................................................................................2-20Annual Facility Review Checklist ............................................................................................2-21Annual OSHA Safety Program (Exposure Control Plan) Review Form ..................................2-24

Contents

2-4

OSHA Program Manual for Dental Facilities

Definition of an Accident and/or Incident

For the purposes of this program, an accident and/or incident is defined as any unplanned or undesired event which:Results in harm to one or more individuals.Causes property damage.Has the potential for significant human or dollar loss.

When to Investigate an Accident/Incident

The OSHA Safety Officer conducts an accident or incident investigation when:There is evidence of a work-related injury/illness.An accident/incident occurs resulting in significant property damage.Conditions are recognized as being potentially hazardous or unsafe to others.

All occupational injuries or illnesses are investigated with the objective of determining the facts that led to the accident, not with the objective of assigning blame. After the facts are assembled, the OSHA Safety Officer evaluates the cause and determines why the accident happened and what can be done to prevent similar accidents in the future.

How to Document an Accident/Incident

Two forms may be used for accident or incident investigation:Accident Report/Sharps Injury LogSafety Report - Use to record staff meetings or Safety Committee meeting minutes when

safety issues are discussed

Master copies of both forms are located behind Tab 8: Master Record Forms.

Recording Accidents or Injuries for OSHA

Federal OSHA requires the recording and posting of accidents or injuries resulting in loss of work days, work restrictions, and treatment beyond first aid (e.g. OSHA logs 300, 300A, 301) except for small businesses with no more than 10 employees and certain exempt business types. Dental practices and laboratories are exempt from the OSHA recordkeeping requirement. State-administered OSHA programs, however, may have different recording exemptions. Finally, even exempt businesses can be required to record injuries if requested by state or federal labor departments for statistical purposes such as the U.S. Bureau of Labor Statistics.

Correcting Unsafe Conditions

Unsafe or unhealthy conditions, work practices, and procedures are corrected in a timely manner based on the severity of the hazard. Our policy is to eliminate all hazards and unsafe work practices immediately, but if the hazard cannot be corrected upon discovery, employees are instructed on how to avoid the hazard or protect themselves from the hazard, or are removed from the hazardous site.

TAB 5: BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

Contents

Exposure Control Plan Introduction ............................................................... 5-1Overview of Bloodborne Pathogens Standard Components ....................... 5-2A Quick Look at Occupational Exposure ....................................................... 5-3Key Provisions and Effective Dates ............................................................... 5-3Universal Precautions ...................................................................................... 5-3

Other Potentially Infectious Materials (OPIM) .........................................................................5-4Implementing Universal Precautions ......................................................................................5-4

Bloodborne Pathogens .................................................................................... 5-5Epidemiology of Bloodborne Pathogens.................................................................................5-5Update on AIDS in the Workplace ..........................................................................................5-8Transmission of Bloodborne Pathogens .................................................................................5-9

Exposure Determination .................................................................................. 5-9Personnel Who Are Occupationally Exposed .........................................................................5-9

Exposure Prone Procedures ...........................................................................................5-9Bloodborne Pathogens Exposure Determination List #1 (Form 8) .........................................5-11Other Personnel Who Could Potentially Be Occupationally Exposed ....................................5-12Employees Who Are Not Occupationally Exposed .................................................................5-12Bloodborne Pathogens Exposure Determination List #2 (Form 9) .........................................5-13

Restricted Access Areas ................................................................................. 5-14Engineering/Work Practice Controls .............................................................. 5-14

Biohazard Labels ....................................................................................................................5-15Handwashing ..........................................................................................................................5-15

When to Wash Hands .....................................................................................................5-16How to Wash Hands .......................................................................................................5-16Artificial Nails ..................................................................................................................5-17

Page

Sharps Safety .........................................................................................................................5-17What to Look for in Safety Devices .................................................................................5-18Sharps Evaluation Procedure .........................................................................................5-18Use of Non-Safe Sharps .................................................................................................5-19

Sharps Containers ..................................................................................................................5-20Sharps Container Maintenance ......................................................................................5-21Sharps Container Disposal Procedure ............................................................................5-21Servicing or Shipping Contaminated Equipment ............................................................5-21

Decontaminating Work and Touch Surfaces ................................................. 5-21Sample Housekeeping Schedule ............................................................................................5-23

Spill Containment Plan .................................................................................... 5-24Spill Cleanup Procedures .......................................................................................................5-24Spills that Contain Broken Glass or Sharp Objects ................................................................5-24

Instrument Sterilization and Disinfection ...................................................... 5-25Transport and Precleaning .....................................................................................................5-25When to Sterilize .....................................................................................................................5-25

Sterilization .....................................................................................................................5-26Quality Checks for Sterilization .......................................................................................5-26

High-Level Disinfection ................................................................................... 5-27Keeping Employees Safe during Instrument Disinfection .......................................................5-27Sterilants/High-Level Disinfectants .........................................................................................5-28

Decontamination .............................................................................................. 5-29Decontaminating Semi-Critical Equipment .............................................................................5-29Decontaminating Non-Critical Patient Care Equipment ..........................................................5-29Decontaminating Personal Protective Equipment (PPE) ........................................................5-29

Eyewashes ........................................................................................................ 5-30Number & Placement of Eyewash Stations ............................................................................5-30Eyewash Maintenance ............................................................................................................5-31

Eyewash Checks ............................................................................................................5-31

Waste Disposal ................................................................................................. 5-31Biomedical Waste Disposal ....................................................................................................5-31Hazardous Waste Disposal ....................................................................................................5-32Waste Handling & Storage .....................................................................................................5-33Laundry ...................................................................................................................................5-33

Personal Protective Clothing & Equipment ................................................... 5-34Gloves .....................................................................................................................................5-35

When to Wear Gloves .....................................................................................................5-36How to Wear Gloves .......................................................................................................5-36Latex Allergy ...................................................................................................................5-37

Contents

Preventing Allergic Reactions .........................................................................................5-38Face Protection .......................................................................................................................5-38Body Protection ......................................................................................................................5-38Emergency Resuscitation Equipment .....................................................................................5-40

Hepatitis B Vaccine .......................................................................................... 5-40Safety of the Hepatitis B Vaccine ............................................................................................5-41Documenting Employee Hepatitis B Vaccines ........................................................................5-41Titering Employees after the Hepatitis B Vaccination .............................................................5-42

How to Determine Employee Immunity ...........................................................................5-42Testing Employees Vaccinated before the Titer Requirement ........................................5-43

Types of Hepatitis B Tests ............................................................................... 5-43Interpreting Hepatitis B Test Results .......................................................................................5-44

New Employee Hepatitis B Virus (HBV) Vaccination Flow Chart ................. Supplement

Post-exposure Evaluation & Follow-up .......................................................... 5-45What Is an Exposure? ............................................................................................................5-45What to Do after an Occupational Exposure ..........................................................................5-45

When to Get Expert* Consultation for HIV Post-exposure Prophylaxis ..........................5-50Confidentiality of Post-exposure Procedures ..........................................................................5-50Employee Counseling/Precautions .........................................................................................5-51

Occupational Exposure Management Resources ......................................... 5-51Accident Report/Sharps Injury (Form 11) ...................................................... 5-52Post-exposure Checklist (Form 14) ................................................................ 5-54Post-exposure Medical Evaluation Declination Form (Form 15) ................. 5-55Injection Safety ................................................................................................. 5-57

Information for Providers ........................................................................................................5-57Unsafe Injection Practices and Disease Transmission ...........................................................5-58

Frequently Asked Questions: Injection Safety FAQs for Providers ............ 5-58Overview .................................................................................................................................5-58Injection Procedures ...............................................................................................................5-59Resources ...............................................................................................................................5-62

Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens ........................ Supplement

Bloodborne Pathogens Resources ................................................................ 5-63Bloodborne Pathogens Violations in Dental Practices ................................ 5-64

Contents

New employee hepatitis B virus (HBV) vaccination flow chart

Use this flow chart as guide to determine whether to offer a new employee the HBV vaccination in accordance with OSHA’s Bloodborne Pathogens standard.

Record acceptance on Form 13. Schedule vaccination.†† Complete the dosing, titering, and responder sections as information becomes available.

Offer of HBV vaccination is not necessary.

Initiate training and document on Form 19. Go to step 3.

Offer of HBV vaccination is not necessary. Record the documen­tation on Form 13.

Record the declination on Form 16 and have the employee complete Form 12.†

No

No

No

No

Yes

Yes

Yes

Yes

1. The employee is occupationally exposed to bloodborne pathogens. (Check or complete Forms 8 or 9)*

2. The employee has received blood ­ borne pathogens training including information about the HBV vaccina­tion addressing efficacy, safety, method of administration, benefits of vaccination, and that it is at no cost to the employee.

3. There is there no documentation showing the employee having re­ceived the complete vaccination series, immunity status through anti­body testing,** or contra indications for medical reasons.

4. The employee is offered the HBV vaccination and accepts.

See next page for notes and resources.

New employee HBV vaccination supplement Insert after p. 5­44

New employee hepatitis B virus (HBV) vaccination flow chart (cont.)

Notes*Occupational exposure. According to the Bloodborne Pathogens standard, “Occupational exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties” [1910.1030(b)].

**With regard to prescreening for HBV, the employer shall not make prescreening participation a prerequisite for receiving the HBV vaccination [1910.1030(f)(2)(ii)].

In the absence of obtainable HBV vaccination records, the employer may accept a written statement by the employee detailing the date and results of a previous HBV vaccination, according to a February 2007 OSHA standards interpretation letter. In this instance, it would be prudent to also require the employee to sign the HBV vaccination declination form.

In following the recommendations of the USPHS, OSHA does not require serial titering after obtaining the initial titer one to two months after the third dose of the HBV vaccination series. At this time, the USPHS does not recommend HBV booster shots and, therefore, it is not an OSHA requirement. For example, if a newly hired employee produces a HBV vaccination record but no record of a titer, the employer is not required to titer the employee. In the event of a blood or OPIM exposure, treat the exposed employee as vaccinated but non­responder, according to USPHS guidelines.

† The employer must make the HBV vaccination available to an employee who initially declines the HBV vaccination but accepts it at a later date [1910.1030(f)(2)(iii)].

†† After completing training, the employer must provide/schedule the vaccination within 10 working days of the initial assignment and at a reasonable time and location [1910.1030(f)(1)(ii)(A) and (f)(1)(ii)(B)]. This means during paid time.

ResourcesFor more on HBV vaccination and OSHA compliance, see:

OSHA Healthcare Advisor, www.oshahealthcareadvisor.com (search by title):

Ask the expert: Hepatitis B vaccination and titer

Ask the expert: New employee with hepatitis B vaccination, but no titer

Ask the expert: Recommendation for hepatitis B booster

Ask the expert: Timing for hepatitis B vaccination and titer

OSHA expects extra steps when documenting hepatitis B vaccinations

“Hepatitis B and the healthcare worker” by the Immunization Action Coalition, www.immunize.org/catg.d/p2109.pdf

5-45

OSHA Program Manual for Dental Facilities

Post-exposure Evaluation & Follow-upIn spite of employees’ best efforts to the contrary, accidents do happen. All workers must know how to respond quickly and correctly to accidental injuries and that post-exposure evaluations and follow-up are at no cost to the employee.

What Is an Exposure?For OSHA purposes, a reportable exposure event is:

A cut to the skin or a mucous membrane from an article contaminated with blood or OPIM (e.g., needlestick).

A splash or spray of blood or OPIM to non-intact skin or to a mucous membrane.

Note that splashes or sprays to intact skin are not considered exposure events for OSHA purposes.

What to Do after an Occupational ExposureOSHA requires that dental facilities follow the most recent Public Health post-exposure guidelines current at the time of the employee exposure. The following information is taken from the most current CDC guidelines (MMWR, Recommendations and Reports for HBV* and HCV*: June 29, 2001 / 50 (RR11); 1-67; for HIV*: September 30, 2005 / 54 (RR09); 1-17 and December 14, 2007 / 56(49); 1291-1292). Whenever new guidelines are released, this OSHA Program is updated via HCPro’s Medical Environment Update.

* Note: the ’05 & ‘07 CDC guidelines apply only to HIV exposures. Recommendations regarding HBV and HCV are unchanged from those published in ‘01. HBV/HCV are not included in the ‘05 & ‘07 guidelines.

STEP 1. Provide immediate care to the employee’s exposure site:

Wash with soap and water. If appropriate, bandage the site. Flush contaminated mucosal and conjunctival sites with large quantities of water using

an eyewash for at least 15 minutes (See Tab 5: Decontamination for more information about eyewashes).

STEP 2. Report accidents as soon as possible to the OSHA Safety Officer. HIV post-exposure prophylaxis (PEP) is best started within 2 hours of the HIV exposure. Therefore, time is of the essence. Give the OSHA Safety Officer information needed to complete the Accident Report/Sharps Injury located behind Tab 8 (Form 11) and also located on page 5-52. Failure to report an exposure incident is a serious offense. The fact that an exposure incident is reported will not reflect negatively on an employee. If subsequent investigation reveals violation of personal protective equipment use or other procedures required by this Exposure Control Plan, disciplinary action is limited to those violations.

STEP 3. Obtain consent* from the source patient to draw blood to test for HBV, HCV, and HIV infection:

Test known source for HBsAg, anti-HCV, and HIV antibody (order a STAT rapid test for HIV so PEP can be started right away if needed). If the source person is NOT infected with a bloodborne pathogen, further follow-up of the exposed worker is NOT necessary.

5-64

OSHA Program Manual for Dental Facilities

Bloodborne Pathogens Violations in Dental PracticesHCPro, Inc., obtained a report on OSHA violations for dentists’ offices and clinics from July 1, 2009, to June 30, 2010. The tables below show the most frequent and expensive bloodborne pathogens citations

Most frequent violations for dental offices

Ranking PART 1910 Occupational Safety and Health Standards Average initial fine

1 1910.1030(c)(1)(i) Employer does not have a written exposure control plan designed to eliminate or minimize employee exposure.

$854

2 1910.1030(g)(2)(i) Employee training not provided at no cost to the employee and not during working hours.

$447

3 1910.1030(f)(2)(iv) Employer not having signed documentation for employees declining the B vaccination.

$70

4 1910.1030(d)(2)(i) Engineering and work practice controls not used to eliminate or minimize employee exposure.

$885

5 1910.1030(c)(1)(iv) Exposure control plan not reviewed and updated at least annually and whenever necessary to reflect new tasks and procedures.

$484

6 1910.1030(g)(2)(ii)(A) Training not given at time of initial assignment. $703

7 1910.1030(d)(4)(iii)(A)(2) Improper placement, maintenance, and replacement of sharps disposal containers.

$558

8 1910.1030(c)(1)(v) Failure to solicit or document input from frontline workers on engineering and work practices to prevent exposure from contaminated needles and sharps.*

$1,170

9 1910.1030(c)(2)(i) Missing exposure control plan. $0

10 1910.1030(f)(1) Failure to offer hepatitis B vaccination or post-exposure follow-up.

$420

* Appears on both most frequent and most expensive lists.

Source: OSHA Office of Management Systems.

5-65

OSHA Program Manual for Dental Facilities

Most expensive violations for dental offices

Ranking PART 1910 Occupational Safety and Health Standards Average initial fine

1 1910.1030(c)(1)(iv)(A) Exposure control plan update does not reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens.

$2,500

2 1910.1030(c)(1)(iv)(B) Exposure control plan not documenting annual consideration and implementation of appropriate orommercially available safety devices.

$2,045

3 1910.1030(d)(2)(viii)(B) Improperly labeled sharps disposal container. $1,500

4 1910.1030(d)(4)(ii)(E) Employees reaching into containers of contaminated, reusable sharps.

$1,500

5 1910.1030(f)(3) Confidential medical evaluation not made available to employee after an exposure incident.

$1,500

6 1910.1030(g)(2)(vii)(D) Training does not include an explanation of the exposure control plan and the means by which employees may obtain copies.

$1,500

7 1910.1030(c)(1)(v) Failure to solicit or document input from frontline workers on engineering and work practices to prevent exposure from contaminated needles and sharps.*

$1,170

8 1910.1030(f)(2)(i) Hepatitis B vaccination not made available after training and within 10 days of assignment.

$1,130

9 1910.1030(d)(4)(ii) Equipment contaminated with blood and OPIM not cleaned.

$1,000

10 1910.1030(d)(3)(iv) PPE not cleaned or laundered at no expense to employee.

$925

* Appears on both most frequent and most expensive lists.

Source: OSHA Office of Management Systems.

TAB 9: OSHA REGULATIONS & KEY CONTACTS

Contents

OSHA RegulationsBloodborne Pathogens Standard............................................................................................9-1Amended Bloodborne Pathogens Standard (Sharps Safety) .................................................9-13Hazard Communication Standard ...........................................................................................9-14Exit Routes, Emergency Action Plans, and Fire Prevention Plans .........................................9-29Ionizing Radiation ...................................................................................................................9-34Other OSHA Standards for Dental Facilities ...........................................................................9-42

Additional OSHA ResourcesSuggested Work Restriction for Employees ...........................................................................9-43

Key ContactsOSHA Consultative Services State Directory .........................................................................9-47Directory of States with Approved OSHA Plans ......................................................................9-50

Acronyms used in the OSHA Program Manual ............................................. 9-52

Page

9-52

OSHA Program Manual for Dental Facilities

Acronyms used in the OSHA Program Manual

ACLS Advanced cardiac life supportADA American Dental AssociationADA Americans with Disabilities Act AED Automated external defibrillatorsALARA As low as reasonably achievable ALT Alanine aminotransferaseANSI American National Standards InstituteBCG Bacille Calmette-GuérinBSC Biological safety cabinet CD Cytotoxic drugsCDC Centers for Disease Control and PreventionCESQG Conditionally exempt small quantity generators CFR Code of Federal RegulationsCPL Compliance (used as prefix in OSHA compliance directive documents)CPR Cardiopulmonary resuscitationCSHO Compliance safety and health officer CTS Carpal tunnel syndrome CVS Computer vision syndrome DEA Drug Enforcement Administration DOL Department of LaborDOT Department of TransportationEAP Employee Assistance ProgramECP Exposure control planEPA Environmental Protection AgencyEtO Ethylene oxide FDA Food and Drug AdministrationFIFRA Federal Insecticide, Fungicide, and Rodenticide Act FOM Field Operations Manual HAVl Hepatitis A virus HBIG Hepatitis B immune globulinHBV Hepatitis B virusHCV Hepatitis C virusHCW Healthcare worker

9-53

OSHA Program Manual for Dental Facilities

HEPA High-efficiency particulate air HIV Human immunodeficiency virusILI Influenza-like illness LAIV Live attenuated influenza vaccine LQG Large quantity generators LSO Laser safety officerMMR Measles, mumps, rubella MMWR Morbidity and Mortality Weekly ReportMRSA Methicillin-resistant Staphylococcus aureusMSD Musculoskeletal disorderMSDS Material safety data sheetNFPA National Fire Protection AssociationNIOSH National Institute for Occupational Safety and Health NRC Nuclear Regulatory Commission NZ: Neutral zone OPIM Other potentially infectious materialOSH Act Occupational Safety and Health ActOSHA Occupational Safety and Health AdministrationPAPR Powered air purifying respirators PASS Pull, aim, squeeze, sweepPEL Permissible exposure limitsPEP Postexposure prophylaxis PPD Purified protein derivative PPE Personal protective equipmentRACE Rescue, alarm/activate, contain, extinguish/evacuateRCRA Resource Conservation and Recovery Act RSO Radiation safety officer SQ Small quantity generatorTd/Tdap Tetanus, diphtheria, pertussis TIV Trivalent (inactivated) influenza vaccine TST Tuberculin skin testTWA Time-weighted average USPHS U.S. Public Health ServiceWHO World Health Organization