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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.

10E

©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

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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 EditorOwen MacDonald, Executive EditorEmily Sheahan, Group PublisherMike Mirabello, Senior Graphic ArtistMatt Sharpe, Production SupervisorJean St. Pierre, 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:

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04/201021773

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IntroductionImportant Information About the Use of this Program .............................. iHow to Customize this Program for Your Workplace ................................ 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 ............................................................................. 1-12

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

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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................................................................................2-4Correcting 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

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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

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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

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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

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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

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Contents

Symptoms of TB ...........................................................................................................7-6Managing Patients with Suspected or Confirmed TB ...........................................................7-9

TB 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 2Annual OSHA Safety Program Review ................................................................................Form 3Weekly Facility Review Checklist .........................................................................................Form 4-A

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Monthly Facility Review Checklist ........................................................................................Form 4-BAnnual Facility Review Checklist ..........................................................................................Form 5Housekeeping 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

TAB 9: OSHA Regulations & Key ContactsOSHA Regulations

Bloodborne Pathogens Standard .........................................................................................9-1Amended Bloodborne Pathogens Standard (Sharps Safety) ...............................................9-13

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Hazard 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

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 ..................................................................................2-4Correcting 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 .............................................................................. 2-12Documenting Employee Training ................................................................... 2-12

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

Page

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

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OSHA Program Manual for Dental Facilities

The following eight tips help lead to a more effective presentation:

Plan the event – Set objectives, limit the focus of your talk, and project your belief in the subject matter.

Involve management – The training program will only achieve its objectives if management is committed to employee safety. Have a member of management in attendance to clarify policies.

Be creative – Use audio, visual, role plays and hands-on material to increase employees’ retention of the information. Use techniques that best communicate to your specific employees.

Demonstrate – Use props in cases where it’s more effective to demonstrate the use of an item than explain it.

Keep it moving – The most effective speakers move throughout the room. Create activities, which allow audience participation from the front row to the last.

Use employees as teachers – Let the audience relate the subject matter back to their own real world experiences. Listen to the examples offered and expand on them.

Help employees buy into the process – The best training information is worthless if employees do not see how it will benefit them. Use specific on-site accident examples to show the relevance of the program to their own safety.

Head off opposition – Use off-the-job examples if the group is resistant to someone telling them how to do their work. Off-the-job examples drive the point across in a much less threatening way.

Interactive Safety Training Exercises

A good safety program involves not only management commitment but employee involvement. Employees will retain more information and practice safety procedures if safety training is interesting and interactive. The following suggestions can be included in employees’ annual training or can serve to reinforce management’s commitment to this OSHA Safety Program at staff meetings.

General SafetyDemonstrate the location and operation of the eyewash(s).Demonstrate the location of circuit breakers and describe procedures used in the event of

electrical shock injury.State the location of compressed gas cylinders and describe precautions regarding their

use.Describe hazards of radioactive materials and precautions regarding their use.

Fire SafetyState location of fire alarms and extinguisher(s) and demonstrate or describe their use. Identify location of evacuation routes from the building.

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Explain procedures to follow in the event of a fire (the ARACE procedure).Participate in a mock fire drill.

Bloodborne Pathogens SafetyDescribe the protocol for cleaning up splashes and sprays of saliva.Describe the protocol for disposal of sharps/used needles. Locate the Exposure Control Plan.Demonstrate aseptic removal of gloves.Describe when protective apparel is used.

Chemical Safety Locate the MSDS binder and look up a hazardous chemical with which you work. Then:

- State the primary route of entry for this chemical (skin, lungs, eyes, etc.).- Discuss the symptoms of overexposure to this chemical.- Identify the protective equipment and ventilation that is required when working with

this chemical.- Locate the protective equipment in the area. State location of replacements..- State the emergency first aid procedures for the chemical.

State the location of the chemical spill kit.Demonstrate how to clean up a chemical spill.Demonstrate how to use safety glasses while developing x-rays and while mixing,

pouring or diluting chemicals. Show how to use the silver separator for x-ray developer and fixing solutions.Describe how to manage scrap amalgam in an air tight container prior to collection by a

metal refining company.Show how to shut off the oxygen tank valve.Demonstrate the proper use of the nitrous oxide equipment:

- Instruct on the hazards of recreational use of nitrous oxide - Instruct on the teratogenic effects of nitrous oxide

TB SafetyConduct a role-play for exactly what action to take when a potential TB patient enters the

facility. Discuss the effectiveness of current policies.

Annual Employee Retraining OSHA requires annual traing for employees covered under the Bloodborne Pathogens and Respiratory Protection standards. HCPro also strongly recommends annual retraining on the Hazard Communication Standard (“Right To Know”).

It also makes sense to include miscellaneous safety procedures, such as, violence prevention and fire safety. At least once per year, all employees should be shown the location and proper use of fire extinguishers, fire alarms and exit routes.

2-11


Training Topic Who Must Attend When to TrainAnnual Retraining on Bloodborne Pathogens

Employees named on either Exposure Determination List.New employees with no prior OSHA training.

• Before potential on-the-job exposure.• Annually.• Provide abbreviated training for affected em-

ployees whenever a new procedure is adopted that involves potential exposure.

Annual Retraining on Respiratory Protection

Employees required to wear a respirator.

• Before potential on-the-job exposure.

• Annually.

• When changes in the workplace or the type of respirator render previous training obsolete.

• When employee’s knowledge or use of the respirator indicates retraining is needed.

Annual Retraining* on Hazard Communication

New and current employees who are exposed to hazardous chemicals in the normal course of their duties.

• Before potential on-the-job exposure. • Annually. • Employees who face exposure whenever

a new hazardous chemical is introduced in the workplace.

* HCPro recommends employees complete HazCom training both initially and then annually. Although minimum legal requirements do not dictate annual retraining for employees, we strongly recommend yearly training for those working with hazardous substances. Chemicals are always being added or eliminated from the workplace, so it makes sense to refresh your staff by training each year.

Bloodborne Pathogens Annual Training ContentsAccess to this OSHA Program Manual which includes written policies for OSHA

compliance. The OSHA Program Manual also includes an Exposure Control Plan for the Bloodborne Pathogens Standard.

An explanation of the signs and labels used in this workplace.A general explanation of the modes of transmission, epidemiology and symptoms of

bloodborne diseases (HBV, HCV, HIV).An explanation of methods to recognize tasks that may involve exposure to blood or

other potentially infectious materials and the practices to prevent or reduce exposure.A discussion of the limitations of the above practices to prevent or reduce exposure to

bloodborne pathogens. Information on the types, proper use, location, removal, decontamination and disposal of

personal protective equipment (PPE). Information about the free hepatitis B vaccine, including its efficacy, safety, benefits.An explanation of what constitutes an exposure incident and the procedure to follow if an

exposure event occurs. Information about the type of post exposure follow-up provided by this facility. An opportunity for employees to ask questions of the person conducting training.

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Respiratory Protection Annual Training ContentsWhere the written respiratory protection plan is located and how to access it.An explanation of the requirements of the plan including identification of the program

administrator, respirator selection, medical evaluations, and fit testing.An explanation why the respirator is necessary and how improper fit, usage, or

maintenance can compromise the protective effect of the respirator.An explanation on the limitations and capabilities of the respirator.How to use the respirator effectively in emergency situations, including malfunctions. How to inspect, put on and remove, use, and check the seals of the respirator.What the procedures are for maintenance and storage of the respirator.How to recognize medical signs and symptoms limit or prevent respirators use.

Hazard Communication Annual Training ContentsWhere the Hazard Communication program, including MSDS, is located and how to

access the program.How to protect employees from the hazardous substances they work with (including

precautions to take and protective clothing and equipment to use).Proper labeling of hazardous chemicals.How to read and interpret MSDS and labels.How to recognize if they have been exposed (such as visual appearance or smell).How to clean up a chemical spill.What to do if exposure occurs.How to report an accident or exposure.

New Employee OrientationIn addition to yearly retraining, employees must be trained initially about OSHA regulations as they pertain specifically to the workplace. Use Form 19, the New Employee OSHA Orientation Checklist located in Tab 8: Master Record Forms of this manual.

It’s important not to assume that even employees with a clinical background will know how to protect themselves from hazards in your workplace because general safety knowledge may not transfer to a current work situation.

Documenting Employee Training Document annual employee retraining on Form 20, the Annual Employee Training Record. Document new employee safety training on Form 19, the New Employee OSHA Orientation Checklist. Master copies of these forms can be found behind Tab 8: Master Record Forms.

Retain all training records for at least three years.

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Practical Ideas for Administering the OSHA Safety ProgramAn employee complaint is the number one reason for an OSHA inspector to show up at a dental facility’s door. In fact, most OSHA inspections of dental offices have been initiated by an employee complaint.

Whether it’s the disgruntled employee who sees his complaint as a way to retaliate against a boss or system he perceives as being “wrong,” or a person who has consistently received a deaf ear from management about a perceived hazard, OSHA will come knocking. And OSHA inspectors rarely, if ever, leave your facility without exacting a price.

You can nip potential complaints to OSHA in the bud. Here are some practical suggestions for doing this–the best part is that they don’t cost a penny. Try some or all of them to reduce your real or perceived liability:During every staff meeting, encourage employees to bring up any concerns about their

safety on the job. Then, listen to their responses!When an employee states a concern, show interest and ask for more details. Regardless

of whether that concern is valid, address it and resolve either to fix the problem or allay the employee’s fears if the concern was unfounded.

Bring this OSHA Safety Program Manual to staff meetings to reinforce the fact that your practice has a tangible program that contains policies to ensure staff safety.

Take five minutes at these same meetings to do a safety-related demonstration, such as showing how to remove latex gloves without splashing colleagues, how to clean up a biohazardous spill, how to locate and read a MSDS, etc. These short exercises reinforce your commitment to safety.

Practice emergency drills for fire, violent behavior, and other disasters that could potentially befall your practice. After the drill, critique the staff’s performance and amend your emergency plan.

Finally, the ultimate goal for an OSHA Safety Officer is zero non-compliance and zero exposure incidents. So, make sure employees know exactly what safety measures to take. Also, be sure that employees know that using safe work practices and wearing appropriate protective gear is not optional. Lastly, make sure employees know what happens if there is non-compliance. Disciplinary actions should be fair and consistent: follow an unheeded verbal warning with a written warning. If no corrective action follows, take further disciplinary action and/or termination.

Organizing OSHA Compliance DutiesTo help organize a busy OSHA Safety Officer’s efforts to get a facility in compliance and keep it there, Quality America offers four useful tools:

1. A Weekly Facility Review Checklist (optional but highly recommended).

2. A Monthly Facility Review Checklist (optional but highly recommended).

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3. An Annual Facility Review Checklist (mandatory)

4. An Annual OSHA Safety Program Review Form (mandatory) These forms are located on the following pages as well as behind Tab 8: Master Record Forms (Forms 4, 5, and 3). Use them to document and organize compliance duties.

This facility identifies the need for new engineering controls, changes to the current ones in use (e.g., sharps containers, work practices, sharps devices, protective equipment or clothing), or in employee training, through:Review of employee injury records.Verbal or written communication (complaints or suggestions) from employees.Sharps evaluation forms.Staff/committee meetings.

If it is determined that revisions need to be made, the OSHA Safety Officer ensures imple-mentation of the recommendations by making changes to this OSHA Safety Program. For this purpose, use the Annual OSHA Program Review Form located on one of the following pages and behind Tab 8: Master Record Forms (Form 3).

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WEEKLY FACILITY REVIEW CHECKLIST

Note: A master copy of this form is located behind Tab 8: Master Record Forms (Form 4-A).

Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered “No” to any question, explain on the reverse of this form.

Facility

_____ Are all secondary containers, such as spray bottles and chemical bottles, properly labeled and readable?

_____ Are all sharps containers filled below the “fill” line (or 2/3 full) and positioned firmly so that they cannot be casually knocked over?

_____ Are biohazard waste bags/storage bins in the proper locations (in every area where blood or OPIM is encountered) and functioning properly?

_____ Is the biohazard storage area clean and orderly?

_____ Is the autoclave working properly? Are weekly biological indicator test records complete? (Reference Form 2.)

_____ Are scavenging systems for waste anesthetic gas (hoses, bags, masks, and connections) inspected for cracks and leaks?

_____ Is the eyewash station functioning properly? (Run water for several minutes and disinfect eyepieces, see Tab 5 for details.)

Administration

_____ Have hepatitis B vaccinations been made available to unvaccinated new hires with occupationally exposure to bloodborne pathogens after training and within 10 working days of initial assignment?

_____ Have tuberculin skin tests (TST) been made available to new hires before exposures to patients with TB or within 10 working days of initial assignment?

_____ Is the exam/treatment room set-up and clean-up procedure consistently followed? (Reference Form 7.)

Date: __________________ OSHA Safety Officer: __________________________________

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MONTHLY FACILITY REVIEW CHECKLIST

Note: A master copy of this form is located behind Tab 8: Master Record Forms (Form 4-B).


Facility

_____ Are compressed gas cylinders securely fastened in an upright condition? Are empty or unused gas cylinders capped and properly labeled?

_____ Are exit doors free of blockage, clearly marked, and unlocked?

_____ Are fire extinguishers fully charged, accessible, and in their designated places?

_____ Are all floors and carpets dry and free of tripping hazards?

_____ Are stored items not stacked higher than 5 feet (unless a stepstool is available), stable, and located more than 3 feet from any heat source?

_____ Are PPE (gowns, face shields, gloves, shoe covers, etc.) and respirators (N95s) in the proper location, available in the correct sizes and amounts, and functioning properly?

_____ Are hand cleansers available and in the proper locations?

_____ Are all chemicals labeled legibly so contents and hazards are clearly identified?

_____ Are chemical and biohazard spill kits available and within their expiration date?

_____ Are all first aid kit/crash cart components within their expiration dates?

Administration_____

Have all new employees completed a “New Employee OSHA Orientation” checklist? (Reference Form 26.)

_____Is the MSDS binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, MSDS Binder.)

_____Do the Exposure Determination Lists #1 and #2 reflect new employees with occupational exposure? Have employees who left the facility been removed? Have employees whose job duties changed been added/deleted? (Reference Form 8, 9.)

_____Has a new clinical procedure been implemented which requires face, body, or hand protection? If so, has the PPE table (Tab 5) been updated?


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ANNUAL FACILITY REVIEW CHECKLIST

Mark Yes (Y), No (N) or Not Applicable (NA) for the following OSHA requirements. If you answered “No” to any question, explain in the space provided below or on the reverse of this form.

Note: A master copy of this form is located behind Tab 8: Master Record Forms (Form 5)

General Facility Safety_____ The OSHA poster, “It’s the Law” (or state equivalent poster) is visible to all employees. _____ Exit doors are free of blockage, clearly marked and unlocked. _____ Exit signs are properly lit and backup lights/batteries are functioning. _____ If your facility has 10 or more employees, a written evacuation plan/route is posted. _____ Medical equipment cords have grounded 3-pronged plugs. _____ Extension cords are being used properly (not as permanent wiring). _____ Electrical cords are managed to prevent tripping hazards (not placed under rugs or

across doorways). _____ Electrical cords are in good condition (no frays, defects, etc.). _____ The fire alarm is in proper working order. _____ An appropriate number of fire extinguishers are present/accessible. _____ The fire extinguishers have been inspected and tagged within the last 12 months and

are fully charged. _____ Panic buttons, or public address systems, are in working order. _____ The worksite is maintained in a clean and sanitary condition. _____ Restricted areas (lab, decontamination room, etc.) are designated with signage.

Break Room_____ The break area is free of contamination from blood and other potentially infectious

materials (OPIMs). _____ Employees discard PPE before entering the break area. _____ The break area is free from hazardous chemicals.

Check-in/Reception_____ An up-to-date emergency contact list is posted or present. (Reference Tab 3)

_____ The reception area is free of contamination from blood and OPIMs. _____ Employees discard PPE before entering the reception area. _____ The reception area is free from hazardous chemicals.

Administration Area_____ All employees have undergone OSHA annual retraining on bloodborne pathogens,

hazard communication and TB in the last 12 months and this training is documented. (Reference Form 20)

_____ All new employees received initial OSHA training (if not previously trained) or completed a New Employee Orientation Checklist (if previously trained) and this training is documented. (Reference Form 19)

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(Annual Facility Review Checklist, page 2 of 3)

_____ Employees are trained on the proper precautions, and how to properly don and use, the PPE necessary for their job duties. (Reference Forms 19, 20)

_____ All employees participated in at least one fire drill this year._____ Employees have been trained on how to respond in the event of a fire (R.A.C.E. or

A.R.A.C.E.). (Reference Forms 19, 20)

_____ Employees have been properly trained on how to use a fire extinguisher (P.A.S.S.)? (Reference Forms 19, 20)

_____ All OSHA training records from the last three (3) years are available? (Reference Forms 19, 20)

_____ Exposure Determination Lists #1 and #2 document all employees with risk for exposure. (Reference Forms 7, 8)

_____ The facility has documented all needlesticks and other sharps injuries which occurred this year using the Accident/Sharps Injury Log? (Reference Form 11 )

_____ All employee accidents, near-misses, injuries and complaints (check Safety Report and Accident/Sharps Injury Logs) were examined for trends. The need to change engineering controls, policies or procedures was evaluated. (Reference Forms 1, 11)

_____ In areas where trends were noted above or safer sharps have not yet been imple-mented frontline employees have evaluated new safety devices for possible future implementation. Evaluations have been documented, and evaluation forms are retained. (Reference Forms 9, 10)

_____ Hepatitis B vaccination records (or declination forms) are available for all employees. (Reference Forms 12, 13)

_____ Employee post-exposure medical records (for all employees who sustained a needle-stick or other BBP or chemical exposure) are complete and located in a confidential area. Records are available from the last 30 years. (Reference Forms 11, 14, 15, 16)

_____ Engineering controls are functioning effectively (protective shields have not been removed or broken, and all parts are functioning as intended).

_____ The Hazardous Substances List contains all hazardous chemicals in the facility (check for new chemicals recently brought into use). (Reference Form 17)

_____ MSDS binder(s) are in the proper location (accessible to employees). _____ MSDS are present for all hazardous chemicals in the facility, including fire

extinguishing chemicals. (Reference MSDS binder)

_____ TB skin test (TST) records are on file for all employees. (Reference Forms 22, 23)

_____ The annual TB risk assessment has been performed. (Reference Form 21)

_____ The contents (type and number of items) of the first aid kit have been reviewed and are considered adequate for emergencies anticipated in the facility.

Storage Area_____ Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large

volumes of flammables in a flammable cabinet etc.) and are disposed of properly. _____ Chemicals are labeled legibly with contents and hazards clearly identified. Labels

match the identity on the corresponding MSDS. (Reference Form 17, MSDS binder)

_____ Appropriate PPE (gloves, respirators, goggles/face-shields, aprons) is available/accessible for handling hazardous chemicals. (Reference MSDS binder)

_____ All items are stored at least 18 inches from the ceiling.

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(Annual Facility Review Checklist, page 3 of 3)

Dental Operatories/Patient Care Areas_____ All eyewash stations are in proper working order. _____ Universal Precautions are used when handling all blood and Other Potentially

Infectious Materials (OPIMs). _____ Handwashing facilities (sinks with soap or alcohol gels) are available in all areas

where biohazards and patients are encountered. _____ The biohazard symbol/label is used to indicate the potential presence of BBPs for all

blood & OPIMs. _____ Contaminated items and regulated waste are placed into approved biohazard bags

and containers displaying the biohazard symbol. _____ Biohazard waste bags/storage bins are located in every area where blood or OPIM

are encountered and functioning properly (i.e. they seal). _____ PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is

available in the correct sizes and amounts, and functions properly. _____ Sharps containers are in the proper locations and positioned firmly so that they

cannot be knocked over. _____ Sharps containers are replaced as soon as they reach the “fill line” and not filled

past 2/3 full. _____ The most effective engineering controls are available and functioning correctly

(i.e. safety needles, sharps containers, fume hoods, splash shields)._____ Employees decontaminate and clean work surfaces as soon as contaminated and

at the end of every shift with an appropriate disinfectant? Cleaning/Decontamination Room_____ PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is

available in the correct sizes and amounts, and functions properly? _____ Is appropriate PPE (rubber or vinyl gloves, respirators, goggles/face shields, aprons)

available and accessible for handling hazardous chemicals in the workplace? _____ Employees decontaminate and clean work surfaces as soon as contaminated and at

the end of every shift with an appropriate disinfectant? _____ Chemicals are labeled legibly with contents and hazards clearly identified. Labels

match the identity on the corresponding MSDS. (Reference Form 17, MSDS binder)

_____ Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in an explosion-proof flammable cabinet etc.) and are disposed of properly.

_____ Soaking basins or reservoirs used for decontamination of instruments have tight fitting covers to reduce evaporation of hazardous vapors?

Comments (explain any “No” answer): _____________________________________________

____________________________________________________________________________

____________________________________________________________________________

Date: __________ OSHA Safety Officer*: __________________________________________* Note: Also document this annual OSHA safety program review on Form 3.

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ANNUAL OSHA SAFETY PROGRAM (EXPOSURE CONTROL PLAN) REVIEW FORM

Note: A master copy of this form is located behind Tab 8: Master Record Forms (Form 3)

Date Reviewed By Page # of Changes Summary of Revisions*

*Include evaluations of sharps containers, safety needles and protective equipment.

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Table 3: Recommended HIV Post-exposure Prophylaxis For Percutaneous Injuries

Exposure type

Infection status of source

HIV-PositiveClass 11

HIV-PositiveClass 21

Source ofunknown HIV

status2

Unknownsource3 HIV-negative

Less severe(e.g., solid needle and superficial injury)

Recommend basic 2-drug PEP

Recommend expanded 3-drug PEP

Generally, no PEP warranted; however, consider basic 2-drug PEP4 for source with HIV risk factors5

Generally, no PEP warranted; however, consider basic 2-drug PEP4 in settings where exposure to HIV infected persons is likely

No PEP warranted

More severe (e.g., large bore hollow needle, deep puncture, visible blood on device or needle used in patient’s artery or vein)



Generally, no PEP warranted; however, consider basic 2-drug PEP4 for source with HIV risk factors5

Generally, no PEP warranted; however, consider basic 2-drug PEP4 in settings where exposure to HIV infected persons is likely

No PEP warranted

1 HIV-Positive, Class 1 - asymptomatic HIV infection or known low viral load (e.g., <1,500 RNA copies/mL). HIV-Positive, Class 2 - symptomatic HIV infection, AIDS, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of post-exposure prophylaxis (PEP) should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

2 Source of unknown HIV status (e.g.. deceased source person with no samples available for HIV testing).3 Unknown source (e.g., a needle from a sharps disposal container).4 The designation, “consider PEP” indicates that PEP is optional and should be based on an individualized decision between the exposed

person and the treating clinician.5 If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.

Table 4: Recommended HIV Postexposure Prophylaxis (PEP) for Mucous Membrane Exposures and Nonintact Skin* Exposures

Exposure typeInfection status of source

HIV-Positive,Class 1+

HIV-Positive,Class 2+

Source of Unknown HIV Status§

UnknownSource¶ HIV-Negative

Small Volume** Consider basic 2-drug PEP++

Recommend basic 2-drug PEP

Generally, no PEP warranted§§

Generally, no PEP warranted

No PEP warranted

Large Volume¶¶ Recommend basic 2-drug PEP

Recommend expanded 3 -drug PEP

Generally, no PEP warranted; however, consider basic 2-drug PEP++ for source with HIV risk factors§§

Generally, no PEP warranted; however, consider basic 2-drug PEP++ in settings in which exposure to HIV-infected persons is likely

No PEP warranted

* For skin exposures, follow-up is indicated only if evidence exists of compromised skin integrity (e.g., dermatitis, abrasion, or open wound).+ HIV-positive, Class 1 – asymptomatic HIV infection or know low viral load (e.g., <1,500 ribonucleic acid copies/mL). HIV-positive, Class 2 –

symptomatic HIV infection, AIDs, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

§ For example, deceased source person with no samples available for HIV testing.¶ For example, splash from inappropriately disposed blood.

** For example, a few drops.++ The recommendation “consider PEP” indicates that PEP is optional; a decision to initiate PEP should be based on a discussion between the

exposed person and the treating clinician regarding the risks versus benefits of PEP.§§ If PEP us offered and administered and the source is later determined to be HIV-negative, PEP should be discontinued.¶¶ For example, a major blood splash.

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When to Get Expert* Consultation for HIV Post-exposure Prophylaxis

Delayed exposure report (i.e., later than 24 to 36 hours):- The interval after which there is no benefit from post-exposure prophylaxis (PEP)

is undefined.Unknown source (e.g., needle in sharps disposal container or laundry):

- Decide use of PEP on a case-by-case basis.- Consider the severity of the exposure and the epidemiologic likelihood of HIV exposure.- Do not test needles or other sharp instruments for HIV.

Known or suspected pregnancy in the exposed person:- Does not preclude the use of optimal PEP regimens. However, do not use the drug

Viracept in prophylaxis regimens for women with known or suspected pregnancy.- Do not deny PEP solely on the basis of pregnancy.

Resistance of the source virus to antiretroviral agents:- Influence of drug resistance on transmission risk is unknown.- Selection of drugs to which the source person’s virus is unlikely to be resistant is

recommended, if the source person’s virus is known or suspected to be resistant to >1 of the drugs considered for the PEP regimen.

- Resistance testing of the source person’s virus at the time of the exposure is not recommended.

Toxicity of the initial PEP regimen:- Adverse symptoms, such as nausea and diarrhea are common with PEP.- Symptoms often can be managed without changing the PEP regimen by

prescribing antimotility and/or antiemetic agents.- Modification of dose intervals (i.e., administering a lower dose of drug more

frequently throughout the day, as recommended by the manufacturer), in other situations, might help alleviate symptoms.

*Local experts and/or the National Clinicians’ Post-exposure Prophylaxis Hotline

Confidentiality of Post-exposure ProceduresOSHA does not prohibit offering employee postexposure evalaution and follow-up on site, ac cord-ing to a November 10, 2009 interpretation letter, but it acknowledges that confidentiality is easier to accomplish by using an outside facility such as the employee health department of a local hos - pital. Search for the letter by date at www.osha.gov. The boundary between employer and health-care professional may be blurred in a medical setting in which the physician is both the employer and the evaluating healthcare professional. In such cases during an inspection the OSHA Safety Officer will ensure that requirements for consent and confidentiality have been followed.

Employee evaluation and post-exposure follow-up services are provided at no cost to employees at a reasonable time and place, and under the supervision of a licensed physician or other appro - priately trained and licensed healthcare professional. The healthcare professional prescribes treatment (based on test results, according to current U.S. Public Health Service recommenda-tions) and evaluates any reported illness to determine if the symptoms are related to HIV, HBV or HCV development.

In this facility, post-exposure lab testing and medical evaluations are provided by:____________________________________________________________________________.

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Employee Counseling/PrecautionsCounsel the exposed healthcare worker to follow the CDC recommendations regarding preventing bloodborne pathogens transmission:

Do not donate blood or plasma. Inform sex partners of potential exposure to infection.Avoid pregnancy during the follow-up period.Clean and disinfect surfaces on which blood or body fluids have spilled.Do not share razors, toothbrushes, etc.

Encourage any exposed healthcare worker undergoing HIV Post-exposure Prophylaxis (HIV PEP) to complete a full 4-week regimen. A substantial number of healthcare workers put themselves at risk for seroconversion by discontinuing HIV PEP early due to side effects. The most common symptoms are nausea (26.5%) and malaise/fatigue (22.8%). To promote a full course of PEP, inform healthcare workers about the following options their healthcare provider can prescribe to manage side effect symptoms and allow completion of the full regimen:

Antimotility and antiemetic agents to target specific symptoms. Modifying the dose interval (i.e. administering a lower dose more frequently, if

recommended by the manufacturer).

Provide psychologic counseling for any exposed healthcare worker who becomes anxious, or requests this component of exposure follow-up care.

Occupational Exposure Management Resources

PEPline .......................................... (888) 448-4911 http://www.ucsf.edu/hivcntr/PEPline/index.html

HIV Antiretroviral Pregnancy Registry ............(800)-258-4263 www.apregistry.com/index.htm Fax: 800-800-1052 Research Park, 1011 Ashes Drive, Wilmington, NC 28405 E-mail: [email protected]

FDA ........................................................................... (800) 332-1088 http://www.fda.gov/medwatchReport unusual or severe toxicity to antiretroviral agents MedWatch HF-2, FDA, 5600 Fisher’s Lane, Rockville, MD 20857.

CDC ............................................................................................................................. (800) 893-0485Report HIV infections in healthcare workers and failures of PEP

HIV/AIDS Treatment Information Service ............................................... http://aidsinfo.nih.gov/

5-52


ACCIDENT REPORT/SHARPS INJURY(1 of 2* Pages)

Complete this report for incidents and accidents. Document employee injuries that require more than simple first aid.

Situation/Procedure: __________________________________________________________Date of Incident: ________________________ Time of Incident: ______________________Exact Location of Incident: ____________________________________________________Type of incident: (Check ALL that apply!) Near miss. Patient safety concern. Non-employee injury. Body part involved:_____________________ Employee injury. Body part involved: ________________________ Sharps injury. (Fill out Exposure and Sharps Injury on page 2) Splash/spray to mucous membrane or non-intact skin. (Fill out Exposure

on page 2) Chemical injury: ______________________________ (Attach MSDS.)

(Name of substance) Other. Specify: _________________________________________

Employee name: ________________________________ Employee title: __________________________

Circumstances of the incident: (What happened? How did it happen? Who was involved? What caused the incident?) __________________________________________________________________

_____________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________.

Engineering controls/work practices/protective equipment/safety devices in use at the time of the incident: _______________________________________________________________________

Witness/person familiar with incident: _____________________________________________________

Resolution: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________.

OSHA safety officer signature: ______________________________ Date reviewed: ______________

Supervisor signature: _______________________________________ Date reviewed: ______________

*2nd page used only when indicated above.

(Use reverse if necessary)

(Use reverse if necessary)

TAB 6: HAZARDOUS CHEMICAL & RADIATION SAFETY

Contents

A Quick Look at HazCom ................................................................................. 6-1Determining 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 ...........................................................................................Supplement

Glutaraldehyde Spills ......................................................................................................6-11Testing 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

Page

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

Contents

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A product containing a hazard warning that is available commercially to the general public and is NOT used exactly as directed on the label or is NOT used with the same frequency as the general public would use it.

Bleach.Dry socket paste.Amalgam alloy.Gold based alloys and precious metal alloys for clinical use.Hydrophillic resin coating for dentures.Coating material for resin fillings.Tooth shade resin material.Resin tooth bonding agent.Cavity Varnish.Partially fabricated denture kit.Dental mercury.Base metal alloy, including beryllium-containing alloys. Impression material.Subperiosteal implant material.Base plate shellac.Porcelain powder for clinical use.Bracket adhesive resin and tooth conditioner.Denture relining, repairing, or rebasing resin.Pit and fissure sealant and conditioner.Temporary crown and bridge resin.Calcium hydroxide cavity liner.Root canal filling resin.Tricalciun phosphate granules for dental bone repair.

Substances Not Requiring MSDSAny product that does not bear a hazard warning.A product that does contain a hazard warning, but is available commercially to the

general public and is used exactly as instructed on the label (e.g., some cleansers).Denture cement.Endosseous implant.Karaya and sodium borate with or without acacia denture adhesive.Ethylene oxide homopolymer and/or carboxymethyl-cellulose sodium denture adhesive.Carboxymethylcellulose sodium and cationic polyacrylamide polymer denture adhesive.Ethylene oxide homopolymer and/or karaya denture adhesive.Polyacrylamide polymer (modified cationic) denture adhesive.

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Polyvinylmethylether maleic anhydride (PVM-MA), acid copolymer, and carboxymethlcellulose (NACMC) denture adhesive.

Carbomethylcellulose sodium and/or polyvinylmethylether maleic acid calcium-sodium double salt denture adhesive.

Information Required on MSDS

The identity used on the label (the chemical and common names). If the substance is a mixture, all ingredients which are health hazards and in a con-

centration of 1% or more; for carcinogens, 0.1% or more.Physical and chemical characteristics of the hazardous chemical (such as vapor

pressure, flash points). Vapor pressure indicates how easily ingredients in a chemical substance will change from a liquid to a gas. The higher the number, the more quickly a product will evaporate.

Physical hazards of the hazardous chemical (flammable, explosive, etc.).Health hazards of the hazardous chemical, including signs and symptoms of exposure.The primary routes of entry.The OSHA permissible exposure level and any limit used by the manufacturer.Whether the chemical is toxic or carcinogenic.

YES

YES

YES

YES NO

NO

NO

NO

Is the chemical (drug) labeled as hazardous or dangerous?

Can employees be exposed to it?

Is the chemical used according to the label instructions?

Is the chemical (drug) a common consumer (household) product, and is it used with the same frequency as a

consumer would use it?

MSDS not required. MSDS is required.

MSDS flowchart determination

Source: A Common Sense Approach to Chemical Safety for Medical and Dental Settings, Quality America.

6-5


Precautions for safe handling and use including procedures for cleanup of spills and leaks.Recommended engineering controls, work practice, or personal protective equipment

(PPE).Emergency/first aid procedures.Date of preparation of the MSDS.Name, address and telephone number of the chemical manufacturer.

How to Get MSDSMSDS are available free of charge from the manufacturer of the substance. A Sample MSDS Request Letter is located behind Tab 8: Master Record Forms (Form 18). If requesting MSDS in writing, OSHA may accept a copy of a letter in place of an actual MSDS if an OSHA inspection takes place before the MSDS arrives and if an unreasonable amount of time has not expired. If the MSDS does not arrive from the manufacturer within 30 days, send the letter again and write “second request” on it. MSDS are also available over the Internet at www.msdssearch.com.

Where to Keep MSDS

File MSDS in the binder accompanying the OSHAProgram Manual. Also, provide copies of MSDS at each location where the hazardous sub stance is used, if it is distant from the central location. Be sure employees know where MSDS are kept and that they have easy access to them.

It is permissible to have your MSDS files online or on a computer if employees can readily access the files in the workplace. Be sure to train employees on how to access the MSDS file and that there are nor barriers to online access such as password locked computers. Identify in the hazards communication plan backup measures in case the online system goes down.

HazCom RecordkeepingOSHA’s Hazard Communication Standard does not mention how long an employer must keep MSDS for chemicals no longer in use in the workplace. OSHA does require that you maintain records of employee exposures to hazardous chemicals for 30 years, so it makes sense to keep them for that long. But, there’s no need to keep them in your MSDS binder that is accessible to employees, if they take up too much space. Archiving or filing MSDS that are no longer in use meet the intent of the Hazard Communication standard.

Classification of Hazardous SubstancesChemicals often used in dental facilities are classified as:

1. Corrosive. Corrosive substances destroy tissue and cause permanent changes in the tissue, such as scarring. Common corrosive agents may include ammonia.

2. Toxic. A term that can be applied to almost any substance in quantity. A substance is

6-6


considered toxic if serious biologic effects may follow inhalation, ingestion, or skin contact with relatively small amounts. An example is “Teratogenic substances” which can cause malformation of a fetus. Women who are pregnant or trying to become pregnant should be aware of teratogens in their workplace.

3. Strong Sensitizer. These substances cause little or no reaction upon initial contact, but may cause a marked reaction after subsequent exposures. This category may include some adhesives and detergents.

4. Ignitable. Any chemical that can burn is ignitable. The term includes both flammable and combustible. Flammable liquids have a flash point below 100°F and are classified in Class 1A, Class 1B, or Class 1C. Common flammable items are acetone and alcohol. Combustible liquids have a flash point at or above 100°F but below 140°F and are classified as Class IIIA and Class IIIB.

Flammable & Combustible Liquids

Flammables Have Flashpoints Below 100° F

Class Flash Point

Boiling Point Examples

1A <73° F <100°F Acetaldehyde, Ethyl Ether, Cyclohexane.1B <73° F >100°F Acetone, Benzene and Toluene.1C >73° F <100°F Hydrazine, Styrene and Turpentine.

Combustibles Have a Flashpoint at or Above 100° F

Class Flash Point

Boiling Point Examples

II >100°F <140°F Acetic Acid, Naptha and Stoddard Solvent.IIIA >140°F <200°F Cyclohexanol, Formic Acid and Nitrobenzene.IIIB >200°F - Formalin and Picric Acid.

Storage of Hazardous SubstancesRead all chemical labels carefully to determine other factors for the proper use and storage of hazardous liquids such as ignition temperature, explosive limits (LEL or UEL), vapor pressure, specific gravity and vapor density. Purchase chemicals in a volume that will be consumed before the expiration date.

OSHA does not require the use of flammable storage cabinets unless the total amount of flammable and/or combustible liquids reach amounts given below. The amount of liquid that may be stored outside of a cabinet in any one fire area of a building cannot exceed:

25 gallons of Class IA liquids in containers. 120 gallons of Class IB, IC, II or III liquids in containers.

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660 gallons of Class IB, IC, II or III liquids in a single portable tank.

Not more than 60 gallons of Class I or Class II liquids, nor more than 120 gallons of Class III liquids may be stored in a storage cabinet. Also, not more than three such cabinets may be located in a single fire area.

Local authorities and insurance companies may require the use of flammable storage cabinets in quantities less than that of OSHA.

Maximum Allowable Size of Containers

Container TypeFlammable Liquids Combustible Liquids

Class IA Class IB Class IC Class II Class IIIGlass or approved plastic 1 pt. 1 qt. 1 gal. 1 gal. 1 gal.Metal (other than DOT drums) 1 gal. 5 gal. 5 gal. 5 gal. 5 gal.Safety Cans 2 gal. 5 gal. 5 gal. 5 gal. 5 gal.Metal Drum (DOT spec.) 60 gal. 60 gal. 60 gal. 60 gal. 60 gal.Approved Metal Portable Tanks 660 gal. 660 gal. 660 gal. 660 gal. 660 gal.

The exceptions to this rule are medicines, beverages, foodstuffs, cosmetics, and other common consumer products, when packaged according to commonly accepted practices.

Special Hazard Communication Requirements for California

Dentists with 10 or more employees must post a notice sign in the waiting room that alerts individuals, including their patients, to the possibility of exposure to various chemicals used by that office.

NOTICE TO PATIENTS

Proposition 65 WARNING: Dental Amalgam, used in many dental fillings, causes exposure to mercury, a chemical known to the State of California to cause birth defects or other reproductive harm.

Root canal treatment and restorations, including fillings, crowns, and bridges, use chemicals known to the State of California to cause cancer.

The US Food and Drug Administration has studied the situation and approved all dental restorative materials for use.

Consult your dentist to determine which materials are appropriate for your treatment.

A full-size copy of the notice is also available for downloading on CDA Online, http://www.cda.org/member/news/prop65_poster.pdf. Additionally, CDA has developed Proposition 65 FAQ documents for both dentists and patients to provide information on the issue; the FAQs are also available at CDA Online.

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Hazardous Chemicals with Permissible Exposure Limits (PEL)Some chemicals frequently used in dental facilities that have recommended or required employee exposure limits are shown below. Most dental offices will not be required to monitor these levels since exposures are well below these limits. For instance, dental facilities that store small vials of formaldehyde to transport tissue for pathology testing would certainly fall below the established limits. Glutaraldehyde, which is often used as a high-level disinfectant in dental practices, should also remain well below the permissible exposure limits when diluted in a tightly covered container.

Chemical Exposure LimitBeryllium 2 mg/m3 Ethylene Oxide (EtO) 1 ppm over 8 hours or 5 ppm over a 15-minute period.Formaldehyde 0.75 part per million (ppm) over 8 hours or 2 ppm over a

15-minute period.Glutaraldehyde 0.2 ppm.Mercury 0.1 mg/m3 over an 8-hour shift.Nitrous Oxide 25 ppm.Silica (used in dental labs) 0.05 mg/m3

If there is any question whether employee exposure exceeds permissible limits, contact a local industrial hygiene company to test the HVAC system. These companies will ensure that your workplace air supply system has an adequate number of air changes per hour to reduce or eliminate employee exposure to these chemicals.

Avoiding Overexposure to Hazardous Chemicals

Beryllium-Containing Alloys

Exposure to beryllium vapor or particles can range from contact dermatitis to chronic granulo-matous lung disease, known as chronic beryllium disease (CBD). In addition, beryllium and some beryllium compounds in vapor and particulate form have been shown to be carcinogenic.Potential hazards or risks from exposure to beryllium result from melting, grinding, polishing and finishing procedures. The risk is greatest during the casting process in the absence of an adequate exhaust and filtration system.

With regard to the dental office, reports of toxicity to beryllium-containing alloys are limited to a few cases of transient contact dermatitis, and no cases of CBD have been documented to date with dental practitioners, dental office employees, or patients. In cases where beryllium-containing dental prostheses are ground or polished in the dental office, precautions should be considered to minimize any exposure to beryllium-containing dust.

Recent studies suggest that exposure to beryllium at levels below OSHA’s 2 mg/m3 PEL may have caused CBD in some individuals. Therefore, even in the dental office where exposures

Sterilant Supplement Display as a quick reference guide

Sterilant Safety

1. MSDS Be aware of the safety precautions on the

Material Safety Data Sheet (MSDS) 2. Avoid contact

Gloves made of nitrile or butyl rubber (latex gloves do not provide adequate protection)

Fluid-resistant apron or gown

Goggles and mask or full-face shield Always wash hands after handling

3. Labeling

Label the soaking container with name of the chemical & hazard warning 4. Ventilation

Use in a well-ventilated area

Cover the soaking container at all times except when inserting or removing objects from the solution

5. Symptoms of overexposure

Throat and lung irritation

Asthma-like symptoms

Breathing difficulty

Nose irritation, sneezing

Wheezing

Nosebleed

Burning eyes and conjunctivitis

Rash–contact and/or allergic dermatitis

Staining of the hands

(brownish or tan)

Hives

Headaches

Nausea

quality-america.com 1-800-946-9956

Glutaraldehyde Supplement 2

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are likely to be considerably below the 2 mg/m3 limit, dentists should consider providing their beryllium-exposed staff with National Institute of Occupational Safety and Health (NIOSH)-approved air-purifying respirators equipped with 100-series filters (either N-, P-, or R-type as applicable) or, where appropriate, powered air-purifying respirators equipped with HEPA filters. Clinicians should also note that short-term exposures may exceed the 2 mg/m3 PEL. Use of a surgical type mask does not provide adequate respiratory protection because it does not seal the face or effectively filter out fine particles.

Take the following precautions when using beryllium-containing alloys for dental prostheses:

1. Obtain Material Safety Data Sheets (MSDSs) for all dental alloys used in the dental office.

2. Where possible, substitute alloys that do not contain beryllium for beryllium-containing alloys in dental prostheses (a number of other non-beryllium-containing alloys have been granted the ADA Seal of Acceptance).

3. Conduct all procedures related to grinding or polishing beryllium-containing dental alloys using properly designed and installed local exhaust ventilation.

4. Equip vacuum systems and local exhaust ventilation systems with high-efficiency particulate air (HEPA) filters.

5. When possible, use local exhaust ventilation (hoods) properly to minimize the generation of dust when working with beryllium-containing alloys.

6. Use HEPA vacuums to clean equipment and the floor around the work area. 7. Monitor employee exposures to airborne beryllium dust, using personal sampling

techniques on a regular basis, to ensure that beryllium exposures are below the OSHA Permissible Exposure Limits (PEL, below 2mg/m3) and are as low as feasible.

8. Limit the number of office staff who have access to areas where beryllium-containing alloys are being ground or polished.

9. To minimize skin contact and to reduce take-home exposures and beryllium contamination of non-work areas, ensure that protective clothing is worn in areas where dental prostheses containing beryllium alloy are being ground or polished.

Glutaraldehyde

Glutaraldehyde is used to disinfect heat-sensitive instruments. Employee exposure leads to a variety of negative health effects including asthma, breathing difficulties, respiratory irritation, and skin rashes. The most serious adverse health effect is occupational asthma. In addition to causing respiratory effects, glutaraldehyde is a contact allergen, giving rise to contact dermatitis, on the hands and occasionally on the face. Skin sensitization from contact with glutaraldehyde has been documented as well.

To avoid skin and mucous membrane contact, use the following personal protective equipment when working with any high-level disinfectant:Gloves made of nitrile or butyl rubber (latex gloves do not provide adequate protection).

Elbow-length gloves are preferred.Fluid-resistant aprons or gowns. Use sleeve protectors if gloves do not protect forearms. Goggles and mask or full-face shield.

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Always wash hands after handling glutaraldehyde.

NIOSH recommends that workers not be exposed to glutaraldehyde vapor levels above 0.2 ppm. When working with glutaraldehyde, do so in a well-ventilated room (capture velocity of at least 100 feet per minute) with at least 10 room air exchanges per hour (15 or more exchanges are optimal). With one or two tightly covered soaking solutions in a well-ventilated room (with at least 10 air changes per hour), concentrations most likely will range from 0.01 ppm to 0.1 ppm, below the NIOSH-recommended exposure limit of 0.2 ppm.

Workers’ highest risk for exposure to glutaraldehyde in a dental practice comes when the solution is poured into or out of the soaking bins and when inserting and removing instruments. Safety nozzles reduce splashing and “glugging” during pouring, thereby lowering glutaraldehyde vapor levels. Unscrew nozzles carefully after use to prevent additional aerosols. Using narrow and deep soaking bins reduces the surface area and lessens employee vapor exposure when inserting and removing instruments. Also, consider keeping rooms with soaking bins cool, as reduced temperature helps prevent vapor formation.

If glutaraldehyde is used extensively or if soaking bins are not tightly closed, employee exposure may exceed safe limits, at which time employees would be required to wear glutaraldehyde badges for a time to establish baseline air levels. If this initial reading exceeds a safe level, a fume hood or sophisticated ventilation system is necessary to reduce glutaraldehyde air levels. Purchasing automated processing equipment or manual mobile stations to disinfect instruments can also reduce staff exposure levels.

Symptoms of overexposure to glutaraldehyde include:Throat and lung irritation. Asthma-like symptoms.Difficulty in breathing.Nose irritation and/or sneezing.Wheezing.Nosebleed.

Before using glutaraldehyde, be sure employees follow these policies and procedures: 1. Have an MSDS on file and make sure all employees know the safety precautions to take. 2. Place a warning label that states the name of the chemical on the soaking container.3. Rinse and clean instruments to be disinfected prior to soaking. This removes bacteria and

viruses in device lubricants. 4. Those who rinse instruments must protect themselves from splashes and sprays by

wearing gowns, gloves, and face protection. 5. Use in a well-ventilated area with at least 10 air changes per hour. Cover the soaking

container at all times when not inserting or removing objects. 6. After precleaning, rinsing, and drying instruments, precisely follow the manufacturer’s

instructions for high-level disinfection.7. Carefully place precleaned instruments in the disinfectant, making sure they are totally

immersed. Use a strainer basket if instruments have sharp edges. Adhere to the manufacturer’s instructions for dilution and immersion time.

Burning eyes and/or conjunctivitis.Rash (contact and/or allergic dermatitis).Staining of the hands (brownish or tan).Hives.Headaches.Nausea.

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8. Wear heavy-duty utility gloves to remove instruments from the solution. Rinse with water. Then, visually inspect prior to stocking for reuse or storage. Be vigilant about areas of the instruments that have serrations and crevices. Store in a clean, dry area.

9. Change solutions at intervals recommended by the manufacturer or more frequently if solutions are degraded. Wet instruments added over time cause solutions to lose their potency. Periodically test t solutions for potency and discard before the expiration date.

Glutaraldehyde Spills

All glutaraldehyde spills have the potential to create vapor concentrations that exceed recom - mended exposure limits, according to OSHA’s Best Practices for the Safe Use of Glutaraldehyde in Health Care. Employers must create a plan for handling glutaraldehyde spills. The plan shouldconsider the physical characteristics of the area where glutaraldehyde is used (e.g., type and effectiveness of ventilation, room size, and temperature) as well as the quantity and concen-tra tion of the solution. Cleanup equipment and personal protective equipment (i.e., eye, hand, body, and respiratory protection) should be readily available.

Whether a spill can be cleaned up safely without the use of neutralizing chemicals and/or a respirator will depend on the factors listed in the section above. When vapor concentrations are unknown, air-supplied, atmosphere-supplying respirators are appropriate.

OSHA’s Best Practices divides glutaraldehyde spills into drips/splashes and large spills. Drips/splashes can be cleaned up by in-house personnel using the procedures listed on page 6-14. Large spills require either specially trained in-house personnel or hazmat professionals. Ad-ditional steps to take for large spills include evacuating the area until the spill is cleaned up and declared safe; donning respirators (if responders are fit-tested for respirator use); containing the spill with spill pillows and booms if needed; neutralizing the spill with a commercial neutralizer or appropriate chemical agents such as sodium bisulfite or glycine; thoroughly rinsing the area and cleaning up supplies with water after removal of the spill; and disposing of rinse water, disposable cleanup supplies, and absorbent mediums according to applicable regulations and the procedures outlined in the facility spill control plan.

Testing the Potency of Glutaraldehyde

OSHA regulations do not address “check strips” to verify the potency of cold sterilants; follow the manufacturer’s instructions for the frequency of checking solutions.

Disposing of Glutaraldehyde

According to OSHA and the U.S. Environmental Protection Agency (EPA), glutaraldehyde solutions may be disposed of as ordinary domestic waste at the end of their use life. Wearing protective garments and face protection, carefully pour the used soaking solution down the drain and flush thoroughly with water. At concentrations of less than 10 ppm in water, glutaraldehyde is readily degraded by sewage systems. If your facility is on a septic system, do not discard used glutaraldehyde down the drain.

Rinse empty quart and gallon containers before discarding. Do not reuse containers.

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Mercury

OSHA requires that employees be given written informed consent before the use of mercury. Elemental mercury vapor is one of the most toxic forms of mercury and should not be breathed. Women who are pregnant should not be exposed to mercury. Any mercury exposure requires that the employee wear an approved mercury filter respirator.

The manner in which dentists operate their equipment dramatically affects the amount of mercury released. Never drill on mercury on high-dry, since levels as high as 4,000 mg/M3 have been measured 18 inches from the drill when using high-dry. Levels over 1,000 mg/M3 are measurable upon opening an amalgam-mixing capsule. If mercury is used in your office, monitor staff members for exposure using mercury sensor badges. Also, test inside storage areas and along baseboards where mercury might have been dropped. Office spills can go undetected for years and are hazardous.

The EPA and the American Hospital Association (AHA) voluntarily agreed to “virtually eliminate” all mercury-containing waste from hospitals by 2005 and to cut in half the volume of all medical waste by 2010. The American Nurses Association also supports these goals. The American Academy of Pediatrics recently asked pediatricians to stop using mercury thermometers and encourages parents to do the same.

When mercury is exposed to air, it vaporizes immediately and may reach harmful levels. If a mercury spill occurs:

1. Evacuate and restrict access to the room. 2. Put on a mask before beginning cleanup.3. DO NOT VACUUM! 4. Use one of these methods to clean up the mercury bead:

A commercial mercury spill kit. Roll the bead onto a sheet of paper. Suck up the bead with an eyedropper.

5. Dispose of according to the spill kit instructions or call your local EPA or the health department for recommendations.

6. Use a fan to speed ventilation and open a window (if possible). Otherwise, close off the room for at least one hour.

For large mercury spills, call the Emergency Response Hotline (open 24 hours) at the Agency for Toxic Substances and Disease Registry: 770/488-7100.

Nitrous Oxide

An employer needs to monitor the work environment for nitrous oxide (N2O) if staff members could potentially be exposed to concentrations in excess of 25 ppm, which is a time-weighted average permissible exposure limit (PEL) for an eight-hour day.

For dental operatories, OSHA recommends a properly installed N2O delivery system that has appropriate scavenging equipment with a readily visible and accurate flow meter (or equivalent

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measuring device), a vacuum pump with a capacity of up to 45 L/min of air per workstation, and masks in a variety of sizes to ensure proper fit for patients.

Work practices to prevent exposures include:Testing for leaks prior to first use each day and every time a gas cylinder is changed Inspecting equipment for worn parts, cracks, holes, or tears prior to first use each dayVerifying appropriate flow rate after activating connections and turning on the

vacuum pump Placing a properly sized mask on each patientEncouraging patients to minimize talking, mouth breathing, and facial movement while

the mask is in place Inspecting the reservoir bag for changes in tidal volume and verifying the vacuum flow

during administrationUsing clinically approved methods to purge the system before mask removal

Effective scavenging equipment, adequate general ventilation, periodic inspection of equipment, semiannual servicing and monitoring of equipment, and adherence to good work practices should keep nitrous oxide exposures within acceptable limits.

For more information on preventing exposures, see Anesthetic Gases: Guidelines for Workplace Exposures, OSHA, www.osha.gov/dts/osta/anestheticgases.

Silica

See page 6-16.

Monitoring Employees for Exposure

If an employer can document, using objective data from the manufacturer, that the PEL limit will not be reached under foreseeable conditions of use, the employer is not required to provide personal monitors. If exposure limits in your workplace fluctuate or reach permissible limits, provide clip-on monitoring badges for employees. Companies that supply air monitoring badges include:

Sources for Chemical Air Monitoring

Assay Technology1070 East Meadow CirclePalo Alto, CA800/833-1258

Healthcare Environments10050 Montgomery Road Suite 283Cincinnati, OH 45242513/563-3015

AirScan Environmental Technologies291 Route 22, Suite 12Lebanon, NJ 08833 800/639-2477

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Labeling Hazardous SubstancesHazardous chemicals are labeled appropriately when bought from the manufacturer, so there is no need to relabel them upon receipt. The label must include: Identity or contents.Chemical name and common or trade name of the contents.Hazard warnings, including words, pictures, symbols, or combinations that convey the

health and/or physical hazards of the container’s contents; these warnings must be specific as to the effect of the chemical and specific target organs involved.

The name, address, and phone number of the chemical manufacturer.

Be sure to label, tag, or mark containers of any chemical that has been transferred to a secondary, unlabeled container with the contents, dilution, and any hazardous warning, including specific effects of the chemical and target organs affected.

Advise the OSHA safety officer if there are unlabeled containers or if a label has become illegible. The OSHA safety officer assures that labels are replaced when deteriorated or illegible.

NFPA Label SystemAlthough OSHA does not specifically mandate the National Fire Protection Association’s (NFPA) standard hazard identification system (see the diamond-shaped, color-coded symbol below), some dental facilities may wish to adopt it to standardize hazard labels. The NFPA system offers hazard assessments for health (blue quadrant), flammability (red quadrant), reactivity/stability (yellow quadrant), and special hazards (white quadrant) at a glance.

In addition, each quadrant shows the magnitude of severity, graded from 0 to 4:

0 = minimal 1 = slight 2 = moderate 3 = serious 4 = severe

♦ The top diamond is RED and contains the flammability hazard rating.

♦ The right diamond is YELLOW and indicates the reactivity rating of the chemical.

♦ The left diamond is BLUE and indicates the health hazard rating.

♦ The bottom diamond is WHITE and focuses attention on any special hazards of the chemical, such as oxidizer, water reactive, or corrosive.

Safety Tips for Working with Hazardous SubstancesAll employees working with hazardous substances are provided with personal protective equipment (PPE) according to specific OSHA standards or, where indicated, by material safety data sheets. These employees receive education regarding when PPE is necessary; how to properly don, doff, adjust, and wear it; the limitations of PPE; and the proper care, maintenance, useful life, and disposal of PPE.

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Other general safety rules for working with chemicals are:Avoid direct contact with hands, face, and clothing, including shoes.Never taste or smell a chemical.Do not smoke, drink, or eat in chemical use and storage areas.Never use any chemical from an unlabeled container.Keep ap propriate safety devices available for employees who work with, or in the vicinity

of, hazardous substances. For example, if a substance could cause eye damage, an emergency eyewash must be available in close proximity to the substance.

If flammable substan ces are present, fire extinguishers and/or fire blankets must be present in the near vicinity. Products with a pH of less than five or greater than nine should not be handled without gloves and appropriate personal protective equipment.

Chemical Spill Cleanup Procedures

1. Act quickly to contain the spill. Cordon off area if an employee or visitor might come in contact with the spill.

2. Check the MSDS (yellow and black binder) for precautions and cleanup instructions.3. Wear protective equipment, including heavy-duty gloves and, if necessary, goggles,

mask, and gown.4. Notify safety officer to report large or dangerous spills before attempting to clean up.5. If chemical spill is toxic or gives off strong fumes, evacuate the area and get professional

help.6. Clean up spill following precautions listed in the MSDS for that chemical.7. Use approved absorbent neutralizing materials or spill kit to wipe up if necessary.8. Disinfect area after cleaning. Allow to air-dry.9. Dispose of all contaminated material in proper hazardous waste container.

Chemical Exposure to Skin

1. Remove contaminated clothing as quickly as possible. 2. Check the MSDS for recommendations.3. Flush the area of contamination thoroughly with large amounts of water.4. Wash area with soap and water.5. Do not use creams, lotions, or salves on the skin without asking for medical advice.

Medical Consultation & Injury EvaluationEmployees who need medical attention due to a chemical exposure will use the health services at the following facility:

_____________________________________ _________________________ Name of healthcare facility Telephone number

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If an employee requests evaluation by a personal physician, that request will be honored. Medical evaluations and consultations are performed by or under the supervision of a licensed physician without cost to the employee, without loss of pay and at a reasonable time and place.

Employees will be medically evaluated when:Signs and symptoms are consistent with a chemical exposure.Environmental monitoring reveals an exposure level above the proper threshold, if

appropriate (formaldehyde, etc.).

The OSHA Safety Officer will provide the following information to the referring physician: Identity of the hazardous chemical to which the employee was exposed.A description of the conditions under which exposure occurred.A description of the signs and symptoms of exposure.A copy of the MSDS for the chemical involved.

Hazardous Chemical Waste Packaging & DisposalRead the MSDS carefully for guidance on disposal of hazardous chemicals. The Resource Conservation and Recovery Act (RCRA) statutes of the Environmental Protection Agency (EPA) affect the handling of chemical hazardous waste (not infectious waste). Most dental offices are affected by RCRA (or its state-administered counterpart) because they generate chemical hazardous waste, although those that generate less than 100 kg (about 27 gallons) per month are classified as small-quantity generators that are conditionally exempt from RCRA. Facilities that generate between 100 kg and 1000 kg per month are considered small-quantity generators and must obtain a 12-digit EPA identification number. Hazardous wastes must be tracked from the time it is generated until its disposal with a manifest system (cradle to grave) and shipped in EPA-approved hazardous waste trucks.

Typical healthcare hazardous wastes are: Acetone methanol Mercury Ethyl ether Methanol Potassium cyanide Formaldehyde Nitrogen dioxide Toluene Epinephrine base*

Regardless of your RCRA classification, do not discharge pollutants into the water/sewer system without first verifying with local publicly owned treatment works that it meets your state’s criteria for discharge. For more information about disposing of chemical hazardous waste, see the Hazardous Waste Disposal section in Tab 5, or contact your state or local EPA office.

* In October 2007 the EPA determined the scope of the epinephrine hazardous waste listing is only epinephrine base, and does not include epinephrine salts. Most, if not all, of the epinephrine used in medical applications is one of several epinephrine salts. The EPA statement applies to the federal level only. As most states implement their own EPA programs, some may regulate epinephrine salts more stringently than the federal regulations. Therefore, we recommend you contact your state agency to determine the regulation in your state, especially if your facility is located in California, Minnesota, Michigan, Oregon, Rhode Island, or Washington (where laws are typically stricter than the federal regulations.) Find your state contact information at www.epa.gov/osw/wyl/stateprograms.htm

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Special Precautions for Dental Labs

SilicosisSilicosis is a disabling and incurable lung disease caused by breathing in fine dust containing crystalline silica. Once in the lungs, this dust causes damage that stops the body from using oxygen properly. Breathing in dust containing crystalline silica has been linked to other diseases such as tuberculosis, kidney disease, and lung cancer. Silicosis has been diagnosed and confirmed in dental laboratory workers.

Dental lab materials that contain silica are:

Sand Investment materials Porcelain Shop dust

Tasks in a Dental Lab that Can Cause Silica Exposure

Casting – Exposure can occur when mixing investment materials and during divestment of castings. Investment materials often contain large amounts of cristobalite. Cristobalite is a very toxic form of crystalline silica.

Sandblasting – Sandblasting of castings can cause exposure to the investment material or the sand itself. Silica sand is often used to clean castings. It contains almost 100% crystalline silica. Exposure can also occur when the blasting box has leaks. Opening the door of the blasting box before the dust has settled or been removed by a dust collection system is dangerous.

Grinding porcelain – Silica content in porcelain varies. Exposure can occur when mixing porcelain powders or when grinding or polishing dried porcelain material.

Cleaning/Maintenance – Tasks that involve cleaning dusts that contain silica pose a major hazard if dust is raised. The same is true when maintaining local exhaust ventilation or dust collection systems.

Controlling Exposure to Silica

Substitution – The ideal method to stop exposure is to eliminate materials containing crystalline silica. This method is most feasible for sandblasting media. Aluminum oxide is one of many acceptable substitutes.

Ventilation – When there are no good substitutes, dust exposure should be minimized through the use of local exhaust ventilation systems. These systems capture dust at its source and transport it to a dust collection system.

Respirators – The worker should wear a respirator when other control methods are missing or do not work. The type of respirator recommended is, at a minimum, a half-mask air-purifying respirator with type N-100 particulate filters.

Good housekeeping – Wet wiping, wet mopping, and vacuuming with a HEPA vacuum are recom-mended. Dry sweeping, dry dusting, use of compressed air, and use of ordinary vacuum cleaners should be avoided because they reintroduce the dust into the air.

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Other Potential Health Hazards Associated with Working in a Dental Lab

Methyl methacrylate – Used in making dentures and plates, it can be absorbed into the body by inhalation, through the skin, and by ingestion. It is irritating to the eyes, skin, and respiratory tract. Repeated and prolonged exposure can cause skin sensitization and asthma, as well as adverse effects on the nervous system.

Electroplating chemicals – The process of electroplating can release hazardous contaminants into the air that pose a variety of risks to the dental lab worker. The contaminants include various acid and alkaline mists that can cause respiratory and skin problems.

Metals – such as beryllium, chromium, cobalt, and nickel. These metals in alloys used for castings of bridge framework and other dental prosthesis components can cause a variety of lung problems.

Noise – grinding, sandblasting, and other dental lab machinery can make noise that may cause hearing loss.

Chemical sterilants – These are used to sterilize impressions and prosthetic devices, received from dental offices, contaminated with blood and saliva. Sterilant chemicals include aldehydes, phenols, and quaternary ammonium compounds. These chemicals may cause lung problems and dermatitis.

Allergic Reactions to Dental ProductsType I allergic reactions can occur with:

EugenolAnestheticsGlutaraldehyde (asthma)ChlorhexidineFormaldehyde (sealers)Metals (gold, nickel)Eugenol, fragrances, flavorings

Type of Reaction Signs and Symptoms

Type I

Immediate hypersensitivity.

IgE-mediated. Protein allergy.

Within minutes of exposure, inflamed itchy redness, watery eyes, runny nose and asthma-like symptoms.

Severe reactions include skin rashes, facial swelling, breathlessness, and rarely, anaphylactic shock.

Type IV

Allergic contact dermatitis with delayed hypersensitivity.

Cell mediated.Chemical allergy.

Non-localized reaction can extend up the forearm. Red, swollen area with bumps, sores and horizontal cracks, appearing several hours after glove contact

May persist for many days.

Type IV reactions can occur with:

Acrylates (bonding agent)Quatemary NH4Expoxies & Resins

- Glutaraldehyde- Chlorhexidine- Formaldehyde

6-19


Gas Cylinder SafetyCompressed gas cylinders are potential hazards, no matter what the size, and correct handling and use are required. All gas cylinders have two potential health and safety hazards: (1) Those related to pressure, and (2) Those related to the chemical properties of the compressed gas. If a compressed gas cylinder is punctured or broken, the gas will be released explosively, propelling the cylinder with dangerous force.

Here are some important policies for safe handling of gas cylinders:

1. Have an MSDS for every compressed gas. Review these sheets for the chemical hazard present in a particular gas. Oxygen gas, for example, is flammable and should be kept away from heat and electricity.

2. Be sure cylinders are legibly marked to clearly identify their contents.3. Use, transport and store cylinders in an upright position, and secure by a chain, collar,

or transport cart to prevent them from falling over. Keep valve covers on cylinders when they are not in use.

4. Regulators are specifically designed for each type of gas to prevent incompatible gases from mixing; therefore, never interchange regulators. Regulators must be tightly secured on full cylinders before the valve is opened. Release the valve slowly, away from the face and eyes. If any hissing is heard, shut the valve immediately. Do not use regulators or fittings that leak. Soapy solutions will form bubbles over leaks and can be used to check fittings. Because gas leaks often cannot be seen, heard, or smelled, it is crucial that faulty fittings not be used.

5. Never use lubricants, sealants or tape to fit a regulator.6. Use only in well ventilated areas. Keep away from heat sources and smoking areas.7. When gas cylinders are replaced, tightly shut the valve even if the cylinder is believed

to be empty. The pressure and flow rate on the regulator should read zero before it is removed. Train those who manipulate cylinders to discriminate the cylinder pressure gauge from the flow rate gauge and interpret their readings. Replace regulators with faulty gauges immediately.

8. Manage inventory so that only a minimal amount of cylinders required are kept at the facility. If cylinders are used infrequently, post received dates and expiration dates. Do not store cylinders indefinitely, and return old or expired cylinders to the manufacturer. Do not remove identification labels on cylinders even if the cylinder is believed to be empty.

9. Store cylinders in areas protected from external heat sources.10. Clearly mark empty cylinders and store as carefully as the full ones because residual

gas may be present. Store empty cylinders separately from full cylinders and dispose of properly. Never place in ordinary trash, particularly if trash is to be incinerated.

In 2001, the FDA issued an alert about the dangers of accidentally connecting cryogenic vessels containing other gases to oxygen delivery systems. The agency said it received reports of seven deaths and 15 injuries over the past four years when patients received gases such as nitrogen instead of the intended oxygen. The FDA reported that two errors usually occur in sequence for this to happen:

A vessel is wrongly identified as containing oxygen.The connector, which is gas-specific, is adapted for use in the oxygen delivery system.

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To combat the problem, the FDA recommends that healthcare facilities:

Carefully check labels to ensure containers hold the appropriate gas. Never try to adapt containers with connectors that don’t fit properly.Train staff on use and connection of medical gas systems.Store medical and industrial grade gases in separate areas.

Electrosurgical Safety (Lasers)During surgical procedures using a laser or electrosurgical unit, thermal destruction of tissue creates a smoke plume that can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde and bioaerosols. It can also contain dead and live cellular material (including blood fragments, although there has been no documented transmission of infectious disease through surgical smoke) and viruses.

At high concentrations, this smoke causes eye and respiratory tract irritation in healthcare workers, and creates visual problems for the surgeon. The smoke has unpleasant odors and has been shown to have mutagenic potential. Recent NIOSH research recommends ways to control airborne contaminants generated by these surgical devices.

OSHA has no standards specific to laser plume or surgical smoke, but safety from such hazards is addressed in the Occupational Safety and Health (OSH) Act of 1970. The General Duty Clause 5(a)(1) requires employers to provide a safe and healthy workplace; the section on Respiratory Protection, 1910.134, recommends use of acceptable engineering controls (such as smoke evacuators) or appropriate respirators to control occupational diseases caused by breathing air contaminated with harmful substances. Moreover, the 1996 ANSI Standard, Z136.3 “Safe Use Of Lasers In Health Care Facilities” lends some guidance for employee safety.

Neither surgical masks nor respirators are optimal respiratory protection for surgical smoke. Smoke evacuators and room ventilation provide much better protection. NIOSH’s recommendation (HC11: Control Of Smoke From Laser/Electric Surgical Procedures) recommends general room ventilation in conjunction with local exhaust ventilation (portable smoke evacuators or room suction systems).

Smoke evacuators contain a suction unit (vacuum pump), filter, hose, and an inlet nozzle. Use a smoke evacuator with a high efficiency in airborne particle reduction and according to manufacturer’s recommendations. Use a capture velocity of about 100 to 150 feet per minute at the inlet nozzle and choose an effective filter, such as a High Efficiency Particulate Air (HEPA) filter, to collect contaminants.

Various filters and absorbers used in smoke evacuators to remove or inactivate airborne gases and vapors require regular monitoring and replacement, and are considered a possible biohazard requiring proper disposal.

Room suction systems can pull at a much lower rate and were designed primarily to capture liquids rather than particulates or gases. If these systems are used to capture generated smoke, users must install appropriate filters in the line and insure that the line is cleared and that filters are disposed of properly. Generally speaking, the use of smoke evacuators is more effective than

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room suction systems to control the generated smoke from nonendoscopic laser/electric surgical procedures.

Be sure all lasers are properly classified. A standard operating procedure must be written for Class IV lasers and is recommended for Class IIIB lasers. Use the manufacturer’s safety information as the basis for this procedure as well as the information contained within this section.

Follow the manufacturer’s safety information to be sure that the control measures recommended have been implemented and that they are adequate for your circumstances. Laser treatment areas must bear appropriate signage or have labels affixed to relevant equipment.

Train employees who work in laser areas about laser safety. Require these personnel to wear eye protection of sufficient optical density to prevent injury from the laser in use. Prescription lens wearers must use appropriate laser safety eyewear as well. Do not use damaged protective equipment.

Ensure skin protection in the form of sunscreen, lab coats and gloves. Take care that hands, arms and other body parts do not intersect the beam. Align laser optical systems (mirrors, lenses, beam deflectors) in such a manner that the primary beam or specular reflectors cannot expose the eye to a level above the appropriate intrabeam maximum permissible exposure.

Safe Laser Practices Keep smoke evacuators or room suction hose nozzle inlets within two inches of the surgical site to effectively capture airborne contaminants generated by surgical devices. Keep the smoke evacuator on (activated) at all times during surgical or other procedures when airborne particles are produced.

At the completion of the procedure, consider all tubing, filters, and absorbers as infectious waste and dispose appropriately. Install new filters and tubing on the smoke evacuator for each procedure. Regardless of the type of smoke evacuator systems you use, regularly inspect and maintain them to prevent possible leaks.

Radiation Safety Policies Restrict access to the x-ray area and mark the door to the area with the “Caution-Radioactive Materials” sign (the magenta and yellow propeller sign). Keep the doors to the x-ray area closed at all times (except for entry of authorized personnel) to prevent scattered radiation outside of the room. Ensure that dental x-ray equipment is operated only by individuals adequately instructed in safe operating procedures and who are competent in the safe use of the particular dental x-ray equipment.

Take all precautions necessary to provide reasonably adequate protection to the health and safety of those who are subject to radiation exposure. Keep necessary exposures As Low As Reasonably Achievable (ALARA); and be sure that the doses received by personnel are kept well below the allowable limits.

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Provide employees who perform x-rays with individual or personal monitoring devices (film badges/pocket dosimeters), preferably on a quarterly basis. This is absolutely necessary for declared pregnant employees. An employee (not declared pregnant) may wear a monitoring device for one three-month period and the results extrapolated to determine an annual exposure. If the exposure is less than 10% of the maximum allowable dose (5 rems), then monitors need not be worn for the remainder of the year. Repeat this procedure annually*.

* Note: If your facility can demonstrate annual exposure for each employee is less than 10% of the maximum allowable dose you may choose to NOT badge operators annually. Document how it was determined that monitor badges are not necessary (usually evidence of prior monitoring for a reasonable period of time) and check with your state Nuclear Regulatory Commission office (if applicable, see state listing below) to ensure this action complies with state specific regulations.

Ensure that dental personnel during patient exposure do not: Hold the patient. Hold the film in the patient’s mouth. Hold x-ray tube housing. Hold the aiming cylinder (also known as PID or pointer cone). Stand in the path of the useful x-ray beam. Stand closer than six feet from the patient being radiographed.

Radiation Safety in Dental PracticeThe Nuclear Regulatory Commission (NRC) has primary responsibility for licensing and regulating nuclear materials. Your facility may also be subject to state regulations. Some states, called agreement states, have contracted with NRC to regulate their own nuclear materials. These states are Alabama, Arizona, Arkansas, California, Colorado, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, Tennessee, Texas, Utah and Wyoming.

OSHA regulates occupational exposure to ionizing and nonionizing radiation [29 C.F.R. § 1910.96 and 29 C.F.R (See Tab 9: OSHA Regulations and Key Contacts)]. OSHA’s regulation pro-vides that radiation exposure should not exceed permissible exposure limits, that warning signs and labels be posted outside regulated areas and on containers of regulated materials, and that employees working in regulated areas be monitored for exposure levels. Compliance with NRC regulations or the regulations of an agreement state is automatic compliance with OSHA’s ionizing radiation regulation.

Protecting Staff from Unnecessary Radiation Exposure During the exposure, dental personnel who perform dental radiography should stand behind a protective barrier. If this is not possible, they must stand at least 6 feet away from the patient and the x-ray tube, not in the path of the primary beam but preferably behind a fixed or mobile barrier such as a wall or movable leaded Plexiglas shield.

To reduce unnecessary exposures increase the distance between the patient (the source of scattered radiation) and the x-ray operator to over 6 feet.

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Ionizing Radiation Exposure LimitsFederal occupational dose levels of radioactive material must not exceed:

Whole body, head and trunk, active blood-forming organs, lenses of eyes, or gonads — 1¼ rems per quarter.

Hands and forearms, feet and ankles — 18¾ rems per quarter.Skin of whole body — 7½ rems per quarter.

Note: Dose limits apply only to occupational exposure, not to intentional exposure for medical treatment.

Keep exposure monitoring records when employees exceed limits (e.g., more than 1.24 rems of radiation to the head per calendar quarter). Keep both past and present exposures to ensure that a new dose will not cause an employee to exceed the exposure limit. Report any employee exposure above the authorized limit to OSHA within 30 days of the exposure.

Limiting Exposure to Women of Childbearing AgeTake precautions to limit exposure to young women, especially if they could be pregnant. Ensure that the dose to an embryo/fetus during the entire pregnancy, due to occupational exposure of a declared pregnant woman, does not exceed 0.5 rem (5 mSv). Once a pregnancy becomes known, the radiation dose of the embryo-fetus should not exceed 0.05 rem (50 millirems) in any month (excluding medical exposure).

Some studies have shown that there is an increased risk of leukemia and other cancers in children if the expectant mother was exposed to a significant amount of radiation. Consider temporary assignment for pregnant employees to tasks that involve less risk of being exposed to radiation. Require pregnant employees who continue to take x-rays to use a protective apron (full-size, half-size, wrap-around, or any other protective clothing appropriate to the situation) while actually exposing patients. Also require them to wear a monitoring device at the abdomen. Be sure the pregnant employee stays out of the x-ray room and behind the protective barrier during exposure.

Inform female employees (both orally and in writing) of possible risks so they can take appropriate steps to protect their offspring. Also, allow employees to ask questions. It is prudent to keep records of this training indefinitely.

Employee TrainingProvide information to occupationally exposed individuals regarding health protection issues associated with exposure to radiation, precautions or procedures to minimize exposure, and the purpose and function of protective devices employed. Inform employees at their initial orientation and at least yearly thereafter. Remind female workers that harmful exposure can often occur before the pregnancy is discovered.

Give the following facts to female employees:

The first three months of pregnancy are the most important as the embryo-fetus is most sensitive to radiation at this time.

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In most cases of occupational exposure, the actual dose received by the embryo-fetus is less than the dose received by the mother, because some of the dose is absorbed by the mother’s body.

At the present occupational dose equivalent limits, the risk to the unborn baby is considered to be small, but experts disagree on the exact amount of risk.

There is no need for women to be concerned about sterility or loss of ability to bear children from occupational exposure.

Once a pregnancy becomes known, radiation dose of the embryo-fetus should be no greater than 0.05 rem (50 millirems) in any month.

The 0.5 rem (500 millirems) dose equivalent limit applies to the full nine months of pregnancy.

Miscellaneous Ways to Minimize Radiation ExposureOther ways to minimize radiation exposure to patients, dental personnel and the public are:

Use the fastest film (E-speed) or digital image receptors. Adhere to proper film processing. Assure adequate and proper x-ray tube filtration, kVp, mA and timer accuracy through

regular maintenance and calibration by a qualified service technician.

Regulation of the Medical Use of Nuclear By-ProductsNRC requires any facility that uses, produces, transfers, receives, acquires, owns, or possesses nuclear materials to:

1. Obtain a license to operate. 2. Comply with safety regulations-occupational dose limits, record keeping, notification

requirements, designation of a radiation safety officer, maintenance of records, and submission of reports to NRC if a radiation incident occurs.

3. Properly dispose of radioactive waste. 4. Be subject to NRC inspections and enforcement actions.

Nuclear Regulatory CommissionNotify the NRC’s 24-Hour Headquarters Operations Center at (301) 816-5100 (NRC Headquarters, 1555 Rockville Pike, Rockville, MD 20852, www.nrc.gov) if certain incidents, misadministration or abnormal occurrences develop.

Immediate NRC notification is required for:

Lost or stolen licensed material.Excessive exposures (levels of radiation or concentrations of radioactive material in an

unrestricted area in excess of 10 times any applicable limit).

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The following incidents require notification within 24 hours:

Exposure of the whole body to ≥5 rems (roentgenequivalent-man).Exposure of the skin to ≥30 rems, or exposure of the feet, ankles, hands, or forearms to

≥ 75 rems.Releases within 24 hours averaging concentrations of 500 times the limit specified for the

particular material.

Contact NRC Headquarters Operations Center for all NRC related concerns. You may also contact NRC’s Toll-Free Safety Hotline at (800) 695-7403.

TAB 8: MASTER RECORD FORMS

Contents

General Equipment and Facility RecordsForm 1 Safety Report…………………..…................ Use to document employee complaints; staff

meeting minutes.

Form 2 Autoclave Log…………………..………........ Use weekly, or as indicated to record performance of biological indicator tests.

Form 3 Annual OSHA Safety Program Review….... Use annually to document that this manual was reviewed and updated.

Form 4-A Weekly Facility Review Checklist................ Use weekly (optional form).

Form 4-B Monthly Facility Review Checklist................Use monthly (optional form).

Form 5 Annual Facility Review Checklist…….......... Use annually.

Form 6 Housekeeping Schedule………..…….......... Use initially.

Bloodborne Pathogens RecordsForm 7 Bloodborne Pathogens Exposure

Determination List #1………………….........Use initially, and whenever new clinical staff is added.

Form 8 Bloodborne Pathogens Exposure Determination List #2………………..….......

Use initially, and whenever new clinical staff is added.

Form 8-A Bloodborne Pathogens PPE Compliance Checklist…………..…...….......

Use periodically to monitor compliance with the PPE sections of the bloodborne pathogens standard.

Form 9 Safety Needle/Syringe Evaluation Form…. Use initially, and whenever new safety devices are under consideration.

Form 9-A Sharps Disposal Container Locations......... Use periodically to monitor compliance for sharps disposal container locations.

Form 9-B Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records........

Use periodically to monitor compliance for sharps disposal container locations.

Form 10 Sharps Evaluation Results Form…….......... Use initially, and whenever new safety devices are under consideration.

Bloodborne Pathogens Employee Medical RecordsForm 11 Accident Report/Sharps Injury Log.............. Use when an employee injury occurs, including sharps

injuries and other bloodborne pathogens exposures.

Form 11-A Sharps Injury Log.........................................Use to compile sharps injury device data for sharps evaluation.

Contents

Form 12 HBV Vaccination Declination Form……....... Use when an employee is given the hepatitis B vaccine or declines this vaccine.

Form 13 HBV Employee Vaccination Form…….........Use when an employee is given the hepatitis B vaccine or declines this vaccine.

Form 14 Post Exposure Checklist…………….…........Use to document that all required actions were taken after a sharps injury or employee exposure to bloodborne pathogens.

Form 15 Post Exposure Medical Evaluation Declination Form………………….................

Use to document a particular employee refusing post exposure testing and treatment.

Form 16 Source Patient Testing Consent Form…………………..…..…..........

Use to obtain consent from a source patient after an exposure incident such as a needlestick.

Hazard Communication Records Form 17 Hazardous Substances List…….……......... Use initially to list all hazardous chemicals in your

facility and when a new hazardous chemical is introduced.

Form 18 MSDS Request Letter…………..…….......... Use when a new hazardous chemical is intro duced to document attempts to procure a MSDS.

Training RecordsForm 19 New Employee OSHA

Orientation Checklist……………………......Use to document initial OSHA training when new staff members are added.

Form 20 Annual Employee Training Record….......... Use annually.

Form 20-A Respiratory Protection Training Record……Use annually.

TB / Infection Control Records Form 21 TB Risk Assessment Results Form…......... Use annually.

Form 22 TST Record……………..………………....... Use as indicated, based on your facility’s risk assessment.

Form 23 TB Skin Test Declination Form………......... Use when an employee declines receiving a TB skin test.

Form 24 TB Exposure Log……………….…...…........ As indicated when employees are exposed to a known TB patient.

Form 25 Influenza Vaccine Log………....………........ Use annually to vaccinate all employees.

Form 25-A Influenza Vaccine Declination Form….......... Use when an employee declines this vaccine.

Form 25-B Declination of H1N1 Influenza Vaccination.. Use when an employee declines this vaccine.


Form 4-A

WEEKLY FACILITY REVIEW CHECKLIST


Facility

_____ Are all secondary containers, such as spray bottles and chemical bottles, properly labeled and readable?

_____ Are all sharps containers filled below the “fill” line (or 2/3 full) and positioned firmly so that they cannot be casually knocked over?

_____ Are biohazard waste bags/storage bins in the proper locations (in every area where blood or OPIM is encountered) and functioning properly?

_____ Is the biohazard storage area clean and orderly?

_____ Is the autoclave working properly? Are weekly biological indicator test records complete? (Reference Form 2.)

_____ Are scavenging systems for waste anesthetic gas (hoses, bags, masks, and connections) inspected for cracks and leaks?

_____ Is the eyewash station functioning properly? (Run water for several minutes and disinfect eyepieces, see Tab 5 for details.)

Administration

_____ Have hepatitis B vaccinations been made available to unvaccinated new hires with occupationally exposure to bloodborne pathogens after training and within 10 working days of initial assignment?

_____ Have tuberculin skin tests (TST) been made available to new hires before exposures to patients with TB or within 10 working days of initial assignment?

_____ Is the exam/treatment room set-up and clean-up procedure consistently followed? (Reference Form 7.)



Form 4-B

MONTHLY FACILITY REVIEW CHECKLIST


Facility

_____ Are compressed gas cylinders securely fastened in an upright condition? Are empty or unused gas cylinders capped and properly labeled?

_____ Are exit doors free of blockage, clearly marked, and unlocked?

_____ Are fire extinguishers fully charged, accessible, and in their designated places?

_____ Are all floors and carpets dry and free of tripping hazards?

_____ Are stored items not stacked higher than 5 feet (unless a stepstool is available), stable, and located more than 3 feet from any heat source?

_____ Are PPE (gowns, face shields, gloves, shoe covers, etc.) and respirators (N95s) in the proper location, available in the correct sizes and amounts, and functioning properly?

_____ Are hand cleansers available and in the proper locations?

_____ Are all chemicals labeled legibly so contents and hazards are clearly identified?

_____ Are chemical and biohazard spill kits available and within their expiration date?

_____ Are all first aid kit/crash cart components within their expiration dates?

Administration_____

Have all new employees completed a “New Employee OSHA Orientation” checklist? (Reference Form 26.)

_____Is the MSDS binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, MSDS Binder.)

_____Do the Exposure Determination Lists #1 and #2 reflect new employees with occupational exposure? Have employees who left the facility been removed? Have employees whose job duties changed been added/deleted? (Reference Form 8, 9.)

_____Has a new clinical procedure been implemented which requires face, body, or hand protection? If so, has the PPE table (Tab 5) been updated?


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