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Healthandsafetylawfor dentalpractice

advicesheet

A3

advicesheet

Healthandsafetylawfor dentalpractice
This advice sheet describes your obligations under current health and safety law. The framework of health and safety law enforcement can look very complex but the underlying principles are simple and, once the principles are understood, application to a particular work situation is largely a matter of common sense. Other BDA publications will be useful in helping you to comply with your health and safety requirements. These are referred to in the relevant sections of the advice sheet and include: BDA Practice Compendium Risk assessment in dentistry advice sheet (A5) Radiation in dentistry advice sheet (A11) Infection control in dentistry advice sheet (A12) Clinical Governance Kit The Checklist at the back of this document will help you assess how well you are meeting your requirements. Good Practice Compliance with health and safety legislation is good practice and this advice sheet will help you to put in place aspects of the legislation that are relevant. If you are working through the BDAs Good Practice Scheme self assessment programme, this advice sheet will help with the requirements of the various commitments and especially commitment 4 to look after the general health and safety of patients while receiving dental care.

advicesheet

Healthandsafetylawfor dentalpractice
contents
Duty of care The role of the Health and Safety Executive HSE inspections Health and safety policy Accidents Anaesthetic gases Asbestos Display screen equipment (DSE) Electricity Fire precautions First-aid and medical emergencies Qualified personnel First aid box Medical emergencies Emergency drugs Infection control Lasers Manual handling Assessing and reducing the risks Good handling technique Medicine storage Mercury Personal hygiene Personal monitoring Operative procedures Dealing with spills Amalgam/mercury waste Amalgam separators Pathological specimens Pressure systems Protective equipment Gloves Eye protection Protective clothing

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04 04 04 05 05 06 06 07 08 08 09 10 10 10 Radiation hazards Risk assessment Hazardous substances Pregnant and nursing mothers Young people Safety signs Stress Ventilation Waste disposal Water supplies Welfare arrangements Working environment Safety Facilities Housekeeping Contact details Health and safety checklist 15 15

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Health and safety law for dental practice

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Duty of care
A dentists responsibilities for health and safety are governed by the Health and Safety at Work etc Act 1974 (HSW Act). The Act seeks to protect all those at work employers, employees and the selfemployed, as well as members of the public who may be affected by the work activities of these people. Failure to discharge the responsibilities laid down by the Act can lead to prosecution by the Health and Safety Executive. An employing dentist has a general duty under the Act to ensure, so far as is reasonably practicable, the health, safety and welfare of employees whilst at work. This duty of care extends to patients and to self-employed contractors who might be on the premises. The professional care of patients and clinical judgment are not covered by the Act. In particular, a dentist should: provide and maintain safe equipment, appliances and systems of work ensure that dangerous or potentially harmful substances or articles are handled and stored safely maintain the place of work, including the means of entrance and exit, in a safe condition provide a working environment for employees that is safe, without risks to health and with adequate facilities and arrangements for their welfare at work provide the necessary instruction, training and supervision to ensure health and safety. Health and safety legislation is increasingly risk-led. Recent legislation places a specific obligation on employers to assess the risks to their employees and others who might be affected by their work activities. The requirement to assess risks may be general as with the Management of Health and Safety at Work Regulations 1999 or specific as with the Control of Substances

Hazardous to Health Regulations 2002 and the Health and Safety (Display Screen Equipment) Regulations 1992. Under the HSW Act, employees are required to take reasonable care for their own and others health and safety and to cooperate with the employer to implement the requirements of relevant legislation. As a last resort, an employees continued refusal to comply with safety rules could provide fair grounds for dismissal (although this decision must only be taken after seeking appropriate advice, from the BDA for example). An approved poster entitled Health and Safety Law what you should know (ISBN 0-71-762493-9) should be displayed in every workplace (Health and Safety Information for Employees Regulations 1989). You will need to add the name and address of the enforcing authority and the address of the Employment Medical Advisory Service for your area. The poster is available from HSE Books (tel: 01787 881165). The role of the Health and Safety Executive The Health and Safety Executive is the statutory body responsible for enforcing the HSW Act and providing an advisory service. An Inspector has the power to: enter premises at a reasonable time examine and investigate all areas of the practice request such information, facilities and assistance as may be needed interview and take written statements from anyone they think might give them information relevant to their investigation. If a health and safety risk is identified, the employer and employees must be told what action will be taken. If there is a breach of legislation, an Inspector can: issue an improvement notice which specifies the legal requirements being broken, what

action is required to put matters right and the period of time allowed issue a prohibition notice, if there is a risk of serious personal injury, which prohibits the carrying on of the activity giving risk until the remedial action specified has been taken seize, render harmless or destroy any substance or article considered to be a cause of imminent danger or serious personal injury. This is clearly a last resort power and would be used only when other powers are inadequate to deal with the situation prosecute anyone contravening a legal requirement, either instead of or in addition to serving a notice.

The Act seeks to protect all those at work

Anyone who is served a notice (an employer, a self-employed person or an employee at the time of serving the notice) may appeal to an Industrial Tribunal within 21 days of the notice being served. An improvement notice is suspended pending the outcome but a prohibition notice remains in force until the appeal is determined. HSE inspections A routine HSE visit might take 30-45 minutes and, although not legally required to give notice before calling, inspectors normally make appointments to visit and do their best to avoid disrupting a practice. Inspectors carry a warrant with an identifying photograph and will produce this for examination if requested. An inspection will generally consist of: an examination of the premises and equipment, with particular attention to anything with an obvious potential danger (radiographic equipment, autoclaves, electrical appliances, and gas cylinders, for example). Inspectors will not undertake technical testing of equipment but will ask about the safety checks that have been carried out and expect to see evidence (reports, certificates etc).
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Health and safety law for dental practice

They can, where necessary, recruit specialist technical support questions about who works in the practice, the protocols and precautions that are followed routinely and what training staff have received in working safely and avoiding hazards. Particular attention is paid to radiographic hazards, the safe use of anaesthetic gases (including ventilation and cylinder storage) and the control of other hazardous substances. Where five or more people work at the practice, the inspector might ask to see the practice safety policy.

Health and safety policy Practices with five or more employees must have a written health and safety policy, which is brought to the attention of all employees ideally each employee should be given a copy. Associates and self-employed hygienists must be included; it is essential that they also comply with the policy. Health and safety policy statements usually consist of three parts: a statement of intent a declaration of the employers commitment to providing a safe and healthy workplace and environment details of responsibilities for health and safety throughout the workplace details of safe systems of work and safe working practices for all work activities. A model safety policy for dental practices is included in the BDA Practice Compendium and the BDA Clinical Governance Kit and can be adapted to suit your practice. A more general safety policy is available from HSE Books (tel: 01787 881165) or downloaded from the HSE website: www.hse.gov.uk/pubns/indg259.pdf

How to comply
Accidents Employers are required to notify the HSE of major accidents (including death) and dangerous occurrences (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR)). Reports to the HSE (Incident Control Centre) can be made by telephone, fax or email without delay to allow any necessary investigation to begin promptly. The employing dentist must also confirm the details in writing within 10 days on Form F2508. Accidents causing more than three days absence from work must also be reported by sending a completed accident report form (F2508) to the Health and Safety Executive within 10 days of the accident no immediate notification by telephone is required. Reports must be submitted using the proper form and there are penalties for failing to notify. Major injuries are defined in the Regulations and include: fractures of the skull, spine or pelvis fracture of any bone in the arm or leg (except in the wrist, hand, ankle or foot) amputation of a hand or foot; loss of sight of an eye loss of consciousness through lack of oxygen

any other injury resulting in a person being injured or admitted to hospital as an inpatient for more than 24 hours, unless detained only for observation.

Practices with five or more employees must have a written health and safety policy

Notifiable dangerous occurrences are also defined in the Regulations and include: explosion, collapse or bursting of any closed vessel, including a boiler or boiler tube, containing any gas (including air) or vapour above atmospheric pressure which could have caused major injury or resulted in significant damage to the plant - for example a compressor or autoclave explosion electrical short circuit or overload attended by fire or explosion causing the equipment to be unusable for more than 24 hours and which could have caused major injury the uncontrolled release or escape of any substance which could caused damage to health or major injury for example a serious mercury spill inhalation, ingestion or other absorption of any substance, or lack of oxygen causing ill health and requiring medical treatment any case of acute ill health where there is reason to believe that this resulted from occupational exposure to isolated pathogens or infectious material.

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Health and safety law for dental practice

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Employers are required to maintain records of all reported injuries and dangerous occurrences, which must include the date and time of the accident, the name and occupation of the person affected, the nature of the injury, the place and circumstances of the accident. Accident books must comply with data protection legislation and appropriate versions are available from HMSO or from HSE Books (tel: 01787 881165). Certain diseases must also be reported and include poisoning, certain skin diseases, hepatitis, tuberculosis, anthrax and bone cancer resulting from radiation. However, a report must only be made if a written diagnosis is received from a doctor. The report form F2508A should be used. The report forms are included in the BDA Practice Compendium and can be downloaded from the HSE website www.riddor.gov.uk/reportanincident .html. More detailed guidance on the Regulations is available from HSE Books: A guide to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (ISBN 0-7176-1012-8). Adverse incidents involving medical devices should also be reported to the Medicines and Healthcare Products Regulatory Agency (formally the Medical Devices Agency). The appropriate reporting forms are available from the BDA. Anaesthetic gases At high concentrations of several thousand parts per million (ppm) all anaesthetic agents reduce activity in the nervous system, leading to anaesthesia. In contrast to patients who may be exposed to these high concentrations a few times in their lives, health care staff may be exposed to much lower concentrations day after day. There is no conclusive evidence to suggest that either exposure to anaesthetic agents has resulted in an increased risk of miscarriage or that exposure to nitrous oxide has caused developmental defects in the foetus. Animal studies have, however, demonstrated adverse effects at

exposure to high levels, so the potential for harm cannot be dismissed. Occupational Exposure Standards (OESs) have been set for the following four anaesthetic agents at which there are no significant risks to health: Anaesthetic agent OES over an 8-hour Time Weighted Average 100 ppm 50 ppm 50 ppm 10 ppm

In dentistry, a mixture of nitrous oxide and oxygen is used in inhalation analgesia for pain relief and anxiety reduction. The main sources of pollution are the patients exhaled breath and leaks from the breathing circuit and facemasks. Where anaesthetic gases are used for only one or two sessions a week, it is unlikely that staff will be exposed to levels in excess of the OES. If you find that you are exceeding the OES you will need to improve the ventilation. Further information can be found in the Health Services Advisory Committees publication Anaesthetic agents: controlling exposure under COSHH, (ISBN 0 7176 1043 8) available from HSE Books. Information is also available from the Department of Health through its guidance document Conscious sedation in the provision of dental care available from the Department of Health website: www.doh.gov.uk Gas cylinders should be stored, if possible, in external well-ventilated stores preferably with piped supplies to the point of use. Many dental surgeries may not have a suitable external storage area that is easily accessible for cylinder deliveries and internal storage may be the only option. Cylinders should be stored within a fire-resisting enclosure with ventilation through an external wall to a safe place outside the building. Stocks should be kept as low as possible and any flammable gases should be kept away from sources of ignition and not be stored with oxygen. Medical oxygen has a three year shelf life and cylinders should be replaced or refilled within this time. Asbestos Under the Control of Asbestos at Work Regulations 2002, dentists who are responsible for maintaining their premises must assess whether asbestos is present on the premises and its likely condition. A record of the assessment should be maintained together with any subsequent reviews. Building plans and the age of the building may be helpful. Parts of the building that are
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Nitrous oxide Enflurane Isoflurane Halothane

Employing dentists have responsibilities to ensure that staff exposure to anaesthetic agents by inhalation should be reduced to the OES. In order to estimate exposure in dentistry, you will need to consider the amount of time staff are exposed to the anaesthetic and how well the room is ventilated. Where nitrous oxide is used as an analgesic, staff could be exposed to high concentrations but if this is only for short periods their average exposures over an 8-hour period are unlikely to exceed the OES. If you cannot easily estimate exposure levels, you may need to carry out some personal sampling as part of your assessment by taking time weighted air samples in the breathing zone of those potentially most exposed. You should visually check (at least once a week) that scavenging and ventilation equipment is working properly and have it regularly serviced in accordance with the manufacturers recommendations and at least every 14 months. Periodically review how you operate scavenging equipment to ensure that it is being used correctly. Make sure your employees are aware of the possible risks to their health, understand why scavenging and ventilation are necessary and how to use the equipment properly.

Employers are required to maintain records of all reported injuries

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Health and safety law for dental practice

accessible should be inspected. Further advice on asbestos management is contained in the HSE guidance document A short guide to managing asbestos in premises (INDG223, rev3), which can be downloaded from the HSE website: www.hse.gov.uk/pubns/ asbindex.htm Display screen equipment (DSE) The use of computers within the practice is becoming increasingly common. Where employees habitually use DSE for a significant part of their normal work, you will have certain obligations (Health and Safety (Display Screen Equipment) Regulations 1992). Where DSE use is more or less continuous on most days, the worker will be deemed to be a user. An employee would also be classified as a user if most or all of the following criteria apply: the job cannot be done effectively or at all without DSE the worker has no discretion over whether to use DSE the job requires significant training or particular skills the worker uses DSE for periods of an hour or more at a time, more or less on a daily basis the task depends upon the fast transfer of information between the worker and screen attention and concentration demands are high, such as where there may be critical consequences of an error. Work involving DSE use should be planned to incorporate breaks or changes of activity. Short frequent breaks are better than longer, less frequent ones and ideally the individual should have some discretion over when they are taken. The workstation must meet minimum requirements. For example, the screen should normally have adjustable brightness and contrast controls, to allow individuals to find a comfortable level for their eyes, helping to avoid the problems of tired eyes and eyestrain. Health and safety training should be provided to make sure
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employees can use all aspects of their workstation equipment safely and know how to make the best use of it to avoid health problems, for example by adjusting the chair, using a wrist pad and foot rest.

Making the best of your DSE workstation

adjust the chair and DSE to find the most comfortable position for working. Arms should be approximately horizontal and eyes the same height as the top of the screen casing make sure there is enough space underneath the desk to move legs freely. Move any obstacles such as boxes or equipment avoid excess pressure on the backs of legs and knees. A footrest, particularly for smaller users, may be helpful dont sit in the same position for long periods. Make sure posture is changed as often as practicable. Some movement is desirable but avoid repeat stretching movements adjust the keyboard and screen to get a good keying and viewing position. A space in front of the keyboard is sometimes helpful for resting the hands and wrists when not keying dont bend the hands up at the wrist when keying. Keep a soft touch on the keys and dont overstretch fingers. Good keyboard technique is important try different layouts of keyboard, screen and document holder to find the best arrangement make sure there is enough work space to take whatever documents are needed. A document holder may help to avoid awkward neck movements arrange the desk and screen so that bright lights are not reflected in the screen. Adjust curtains or blinds to prevent unwanted light make sure the characters on the screen are sharply focused and can be read easily. They shouldnt flicker or move make sure the screen is free of dirt, grime or finger marks use the brightness control to suit the lighting conditions of the room.

Health and safety law for dental practice

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Users can ask the employer to provide eye and eyesight tests. If spectacles are required specifically for working at the DSE, the employer must provide them but not spectacles that are required for any other purpose. The results of the eye and eyesight test can only be disclosed to the employing dentist with the consent of the employee (Access to Medical Reports Act 1988). Electricity Responsibilities concerning the safety of both the fixed supply to the premises and any moveable (portable) appliances come under the Electricity at Work Regulations 1989. The supply to all appliances must be correctly wired and fused and should be installed by contractors registered with an appropriate organisation, for example, the National Inspection Council for Electrical Installing Contracting. Whilst the Regulations do not specify the need for examination and testing, the requirements for suitability, integrity and safety of electrical equipment imply a need for some form of inspection and testing. It is not mandatory to maintain records of inspection and testing but they would help provide evidence that all reasonable steps had been taken to comply with the requirements of the legislation. Electrical equipment must be in good working order at all times. The frequency of inspection and testing will depend upon the type of equipment and the circumstances under which it is used. A piece of electrical equipment in constant use may require six-monthly testing whereas an item which is rarely used may require testing at only twoyearly intervals. Portable electrical equipment is described as equipment that has a cable and a plug and is normally moved around or can easily be moved from place to place (kettle, heaters, fans and televisions, for example) and also equipment that could be moved (photocopiers and desktop computers, for example).

Electrical equipment must be in good working order at all times

Visual inspection is the most important maintenance precaution. The cable and plug can be inspected for: damage to the cable covering (eg cuts, abrasions) damage to the plug (eg cracked casing, bent pins) non-standard joints including taped joints in the cable the outer covering (sheath) of the cable not being gripped where it enters the plug or equipment. Is the coloured insulation of the internal wires showing? equipment that has been used in conditions where it is not suitable (eg wet or dusty workplaces) damage to the outer cover of the equipment or obvious loose parts or screws overheating (burn marks or staining). Inspection could also include the removal of the plug cover and checking that: a fuse is being used (ie that it is a proper fuse and not a piece of wire, a nail etc) the cord grip is holding the outer part (sheath) of the cable tightly the wires, including the earth where fitted, are attached to the correct terminals

no bare wire is visible other than at the terminals and the terminal screws are tight there is no sign of internal damage, overheating or entry of liquid, dust or dirt.

This internal inspection does not apply to moulded plugs where only the fuse can be checked. It is not necessary to have an electrician to carry out the visual inspection, competent members of staff can do it if they have enough knowledge and training and know how to avoid danger to themselves. All earthed equipment and most leads and plugs connected to equipment should have an occasional combined inspection and test by an appropriately trained (competent) person to identify the faults that cannot be found by the visual check. The Health and Safety Executive has suggested intervals of up to five years in low risk environments depending on the type of equipment used. For dental practices every two or three years might be more appropriate. Fire precautions The Fire Precautions (Workplace) Regulations 1997 require you to assess what fire precautions are needed by carrying out a fire risk assessment as part of your general

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Health and safety law for dental practice

risk assessment. The Regulations specify the following requirements for emergency routes and exits: they must be kept free of obstruction at all times and allow employees (and patients) to evacuate the premises quickly and safely where possible they should lead directly to a place of safety they should be appropriately and clearly indicated emergency lighting should be provided where necessary emergency doors must open in the direction of the escape and in an easy and immediate action sliding and revolving doors should not be used as emergency exits. In deciding what fire precautions are appropriate, you should think about: the size and layout of the workplace the work activities, including the equipment and substances that are used the maximum number of people likely to be present at any one time. If there is a fire, it is important that everyone in the workplace is alerted as quickly as possible. Early discovery will allow people to escape safely before the fire takes hold and blocks escape routes or makes escape difficult. All workplaces should have arrangements for detecting and giving warning of fire. In most cases, fires are detected by people in the workplace and no further warning device is needed. But a fire may break out in a part of the practice that is unoccupied and put people at risk, so some form of automatic fire detection system should be considered. If fire breaks out and trained staff can safely extinguish it using suitable fire-fighting equipment, the risk to others will be removed. All workplaces should have suitable firefighting equipment. The water-type extinguisher or suitable alternative is the most useful fire-fighting equipment for general fire risks; one extinguisher for every 200 square metres of floor space is
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recommended with a minimum of one per floor. Where the fire source might be electrical, other types of extinguishers should be considered (carbon dioxide or dry powder, for example). Fire extinguishers should be sited on exit routes, preferably near to exit doors or, where they are provided for specific risks, near to the hazards they protect. Fire detection devices and fire-fighting equipment must be regularly checked to ensure its continued good working order. First-aid and medical emergencies All workplaces must have adequate first-aid provisions, the extent of which depends upon the hazards present and the number of people employed (including associates and self-employed hygienists). Access to first-aid facilities must be available for all employees during working hours, even when shifts are worked. The Health and Safety (First-Aid) Regulations 1981 require you to assess the first-aid requirements of the practice taking the following factors into account: the hazards and risks associated with the work your practice risk assessment will help the number of people at the practice and where they work previous accidents (recorded in the accident book) access to emergency facilities and services arrangements for covering planned and unplanned absences patients although there is no legal requirement to provide first-aid treatment and facilities to non-employees. You must ensure that everyone has reasonably quick access to first-aid. Those who work outside the practice (domiciliary visits, for example) must still be provided with adequate first-aid cover (and may include a mobile telephone). Qualified personnel: Dental practices with fewer than 50 workers are required to have an appointed person on the premises at all times the practice is open.

The basic emergency first-aid course for appointed persons is recommended and should include emergency actions, cardiopulmonary resuscitation (CPR), control of bleeding, treatment of wounds and treatment of the unconscious patient. If you have more than 50 workers or assess the working environment to be hazardous, you will need to ensure that qualified first-aiders are on the premises at all times. Training for first-aiders includes: dealing with emergencies at work administering CPR administering first-aid to unconscious casualties administering first-aid to bleeding or wounded casualties administering first-aid for burns/scalds, bone/muscle/joint injuries, shock, eye injuries, poisonings, casualties overcome by gas or fumes safe transport of casualties recognition of, and appropriate procedures for dealing with, common illnesses competent record keeping and effective communication or information to doctors etc. If your assessment shows that firstaiders are needed in your practice, they will need to attend a course leading to a certificate of competence from a training organisation approved by the HSE. These courses provide at least 24 hours of training, usually over four days or several weeks. First-aid certificates are valid for three years and requalification requires a further 12 hours of training, usually over two days. Dentists are not qualified as first-aiders unless they have undertaken appropriate training. First-aid courses are arranged by a number of organisations, including St John Ambulance and the British Red Cross. First aid box: all dental practices must have at least one first-aid box clearly marked with a white cross on green background. First-aid boxes should contain sufficient quantities of suitable first-aid materials and

You must ensure that everyone has reasonably quick access to first-aid

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nothing else. Minimum quantities for a low risk workplace may be considered as: a general guidance leaflet on first-aid 20 individually wrapped sterile adhesive dressings (assorted sizes) appropriate for the work environment 2 sterile eye pads 4 individually wrapped triangular bandages (preferably sterile) 6 safety pins 6 medium-sized individually wrapped sterile unmedicated wound dressings (approx 12cm x 12cm) 2 large sterile individually wrapped unmedicated wound dressings (approx 18cm x 18cm) 1 pair of disposable gloves. Where mains tap water is not readily available for eye irrigation, sterile water or sterile normal saline solution (0.9%) in sealed disposable containers should be provided. Once opened they should not be re-used. Medical emergencies can occur at any time, so it is imperative that you ensure all members of the dental team are properly trained, have the necessary resources available and are prepared to deal with an emergency, including a collapsed patient. Training should include the preparation and use of emergency drugs (where appropriate) and resuscitation routines in a simulated emergency. This training should occur at least annually. In order to be able to deal with a medical emergency, all dental practices should have available and in working order: portable suction apparatus to clear the oropharynx oral airways to maintain the natural airway equipment with appropriate attachments to provide intermittent positive pressure ventilation of the lungs a portable source of oxygen together with emergency drugs. If you decide to keep defibrillators as

part of your emergency equipment (as these are now readily available and relatively inexpensive), you must be fully trained in their use. Emergency drugs: there is no recommended list of emergency drugs for dental practices you need to decide what drugs to hold considering the treatments you provide and the patients you attend. The Dental Practitioners Formulary contains useful guidelines on the management of the more common medical emergencies that may arise in dental practice and the medicines that should be administered. It is a useful reference when deciding which emergency drugs to keep. If you undertake domiciliary visits, you will need to decide which emergency equipment and drugs should be taken, bearing in mind that a medical emergency may occur during the visit. Infection control Dentists have a duty to take appropriate precautions to protect patients and other members of the dental team from the risk of crossinfection. Failure to employ adequate methods of infection control would almost certainly render a dentist liable to a charge of serious professional misconduct (GDC, Maintaining Standards, November 1997 as amended). The need is obvious for surgery staff to be thoroughly instructed in the handling, decontamination and disposal of instruments to avoid cross-infection, injury from instruments or from sterilising equipment. Basic training in surgery procedures should identify the risks and how they are avoided. To minimise the risk of transmission between patients and between patients and dental clinical staff, a sensible and practicable routine for the prevention of infection and cross-infection should be followed with every patient. The practice infection control policy should be displayed in each surgery to ensure the same infection control procedures are employed.

The BDAs advice sheet on infection control (A12) contains more information on the protocols and precautions that should be in place routinely for all patients and the BDAs Practice Compendium contains a model infection control policy that can be adapted to suit your practice. Lasers Laser equipment is classified from class 1 to class 4 depending on the power output. The classification and labelling of all laser products are the responsibility of the manufacturer. Class 1 lasers are virtually safe but classes 3 and 4 must be used only under medical or dental supervision. Most dental lasers are class 3B or 4. Lasers should conform to BS EN 60825-1:1994 (Radiation safety of laser products, equipment classification, requirements and users guide). Your local Primary Care Trust is responsible for providing health and safety advice about lasers. You will need to appoint a Laser Protection Adviser (LPA), have local rules in place and establish a laser controlled area. Warning signs must be displayed at every entrance. Laser equipment must only be used by staff who have received appropriate training and the equipment should be regularly maintained according to the manufacturers instructions with records kept to show that this has been done. Patients must give informed consent to treatment involving lasers. Manual handling Manual handling injuries currently account for over a quarter of all reported injuries and are the cause of more absences from work than any other cause. Many manual handling injuries build up over time rather than being caused by a single handling incident. The Manual Handling Operations Regulations 1992 set out clear duties for the employer and the employee. Manual handling should be avoided wherever possible and where it
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cannot be avoided the employer must assess the risks and reduce the lieklihood of injury. Employees must make use of the training and equipment provided. The extent of manual handling within the practice must be identified so you need to assess what actions pose a significant risk to employees. Then you need to decide whether it is possible to avoid these actions. Where risky manual handling cannot be avoided, a more thorough assessment is required, which must be documented. Your assessment must not be limited to weight. It should include factors such as the task, the load itself, the work environment and individual capacity.

Manual handling: assessing and reducing the risks What to look for Ways of reducing the risk of injury Can you improve workplace layout to improve efficiency? reduce the amount of twisting and stooping? avoid lifting from floor level or above shoulder height? cut carrying distances? avoid repetitive handling? vary the work, allowing one set of muscles to rest while another is used? Can you make the load lighter or less bulky? easier to grasp? more stable? less damaging to hold? have you asked your suppliers to help? Can you remove obstructions to free movement? provide better flooring? avoid steps and steep ramps? prevent extremes of hot and cold? improve lighting? consider less restrictive clothing or personal protective equipment? Can you take better care of those who have a physical weakness or are pregnant? give your employees more information eg about the range of tasks they are likely to face? provide training?

The tasks: do they involve holding loads away from trunk? twisting, stooping or reaching upwards? large vertical movements? long carrying distances? strenuous pushing or pulling? unpredictable movement of loads? repetitive handling? insufficient rest or recovery time? The loads: are they heavy, bulky or unwieldy? difficult to grasp? unstable or unpredictable? intrinsically harmful eg sharp or hot?

The working environment: are there constraints on posture? poor floors? variations in levels? hot/cold/humid conditions? strong air movements? poor lighting conditions? restrictions on movement or posture from clothes or personal protective equipment? Individual capacity: does the job require unusual capability? endanger those with a health problem? endanger pregnant women? call for special information or training?

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bda advice sheet A3

Training is important but on its own, it cannot overcome a lack of mechanical aids, unsuitable loads and bad working conditions. Training should enable an employee to recognise when manual handling might be harmful, when mechanical aids should be used and good handling techniques. Good handling technique Stop and think: Plan the lift. Where is the load to be placed? Use appropriate handling aids if possible. For a long lift, such as floor to shoulder height, consider resting the load midway on a table or bench in order to change grip. Position the feet: Feet apart, giving a balanced and stable base for lifting (tight skirts and unsuitable footwear make this difficult). Leading leg as far forward as is comfortable Adopt a good posture: When lifting from a low level, bend the knees. But do not kneel or overflex the knees. Keep the back straight (tucking in the chin helps). Lean forward a little over the load if necessary to get a good grip. Keep the shoulders level and facing in the same direction as the hips Get a firm grip: Try to keep the arms within the boundary formed by the legs. The best position and type of grip depends on the circumstances and individual preference; but it must be secure. A hook grip is less tiring than keeping the fingers straight Keep close to the load: Keep the load close to the trunk for as long as possible. Keep the heaviest side of the load next to the trunk. If a close approach to the load is not possible, slide it towards you before trying to lift Dont jerk: Lift smoothly, keeping control of the load Move the feet: Dont twist the trunk when turning to the side Put down then adjust: If precise positioning of the load is necessary, put it down first, then slide it into the desired position

Medicine storage Medicines may undergo chemical or physical deterioration especially when stored in extreme temperatures, damp or direct sunlight. It can reduce their therapeutic effectiveness and, if significant, have serious implications. Medicines should always be stored according to the manufacturers recommendations. The Misuse of Drugs (Safe Custody) Regulations 1973 require certain controlled drugs, that is most schedule 2 and some schedule 3 drugs, to be kept in a locked container or cupboard which can only be opened by the dentist. It is good practice to keep all medicines in a locked cupboard. Police crime prevention officers are available and willing to give advice on this. Stocks of medicines should be kept to the minimum required for routine needs and foreseeable emergencies. Regular stock checks should be carried out and outdated stocks destroyed. Strict records of medicines should be kept. Emergency drugs should be kept securely but be accessible at all times. Mercury All those involved with the handling of mercury in any form should understand its potential hazards and receive training in safe handling procedures to deal with mercury spills, including the safe disposal of contaminated materials. Routine personal hygiene is essential to minimise the possibility of absorbing mercury via skin contact. Careful dispensing, handling and disposal will help the potential hazards of mercury be avoided. The overall risk of mercury is minimised greatly by using pre-dispensed capsules. Working environment: The occupational exposure limit for mercury vapour is 25 micrograms per cubic metre (g/m3) based on a time-weighted average over an eighthour working day. Dental surgeries must be efficiently ventilated to ensure this exposure limit is not
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exceeded. A ventilation system that exhausts to the outside of the building is preferable but, for many surgeries, this is may not be an option. Where ventilation systems are not available, opening a window will encourage a fresh supply of air and help reduce atmospheric mercury below the maximum permitted level. Recycling air conditioning systems are not recommended. Floor coverings in dental surgeries should be non-slip and impervious and should cove slightly up the wall or cabinetry to eliminate crevices. Joints between sheets of floor covering should be kept to a minimum and sealed, and avoided in the vicinity of the dental chair or amalgam preparation area. Tiled floors are not recommended and carpets should never be used. The area where amalgam is prepared should be well ventilated and away from any form of heat (radiator, autoclave and sunlight, for example). The worksurface should be smooth and impervious and, if possible, cove slightly up the wall to prevent mercury accumulating in inaccessible areas. Personal hygiene: Mercury vaporises at room temperature particularly if it is in the form of fine droplets, which have a very large surface area. This vapour can easily enter the body via inhalation and this is now considered the most likely route for mercury uptake in dental staff. Mercury can also be absorbed through the skin but with the routine use of protective gloves this risk has been virtually eliminated. Hands that have been exposed to mercury should be washed immediately with liquid soap in a stream of cold tap water until no stain on the skin is seen. Disposable towels should be used for hand drying. Personal monitoring: Under the Control of Substances Hazardous to Health Regulations 2002 the employing dentist must assess the risk to employees of exposure to mercury, taking into account the amount of work carried out each week, the measures taken to prevent
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spillage and vapour release and the level of ventilation. Those who routinely work with mercury should undergo regular monitoring to ensure they do not exceed the exposure limits. This is particularly important for female dental staff of childbearing age. At present, the simplest form of monitoring for dental health care workers is to measure the concentration of mercury present in the urine using atomic absorption spectroscopy, considered by the Health and Safety Executive to be a satisfactory index of exposure. Urinalysis is available through the UK Mercury Screening Service (tel: 0114 290 0521) and will provide dentists and their staff with an indication of their biological mercury levels and any advice and follow up consultations.

Service and the HSE Infoline (tel: 0870 154 5500). The HSE Guidance Note MS12 Mercury: medical guidance notes provides general information on working with mercury including occupational exposure limits, clinical effects of acute and chronic poisoning, prevention and health surveillance. Amalgam/mercury waste: Amalgam waste or mercury collected from spills should be stored in a sealed, clearly labelled container under a mercury suppressing solution or paste. The disposal of waste amalgam, waste mercury and used amalgam capsules is controlled and must be collected by a person licensed to carry such waste. The relevant paperwork should be completed and kept. Amalgam separators: Amalgam separators reduce the amount of waste amalgam discharged to sewer. There are several types available including gravity fed filtration (sedimentation), centrifugal and ionisation, which can either be fitted to each dental chair or service the whole practice (depending on the type selected). As well as the cost of purchasing the separator, there may be costs associated with installation, which you should check this with the manufacturer. You should also ask about the maintenance and servicing requirements. Pathological specimens Dentists using Royal Mail to send patients specimens to pathology laboratories for diagnostic opinion or tests must comply with the UN 602 packaging requirements. The 602 packaging requirements ensure that strict performance tests (including drop and puncture tests) have been met. The outer shipping package must bear the UN packaging specification marking. Only first class letter post, special delivery or data post services must be used. The parcel post must not be used. Every pathological specimen must be enclosed in a primary container that is watertight and leakproof. The primary container must be wrapped in sufficient absorbent material to

employing dentist must assess the risk to employees of exposure to mercury

Operative procedures: Amalgamators should be placed in a shallow tray lined with aluminium foil. The tray should be large enough to catch any stray droplets, which will combine with the foil and form a non-volatile amalgam. When refilling the mercury reservoir, use a small funnel to reduce the possibility of a spill. Pre-proportioned capsules minimise contact with mercury and further reduces the possibility of a spill. Dealing with spills: Spilt mercury is a hazard and must be cleaned up immediately. A spillage kit should be readily available and include: disposable plastic gloves paper towels a bulb aspirator for the collection of large drops of mercury a suitable container fitted with a seal and a mercury absorbent paste. Commercial kits are available from many dental supply companies. Lead from radiographic packets is also very useful for dealing with small spills, as the mercury combines with the lead to form a non-volatile amalgam. If there is a serious mercury spill, it must be cleaned up immediately and the surgery well ventilated until an assessment can be made of the atmospheric level of mercury. Advice can be obtained from the UK Mercury Screening

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absorb all fluid in case of breakage and then placed in a second durable watertight, leakproof container. Several wrapped primary containers may be placed in one secondary container provided sufficient additional absorbent material is used to cushion the primary containers. Finally, the secondary container should be placed in an outer shipping package that protects it and its contents from physical damage and water whilst in transit. The shipping package must be conspicuously labelled PACKED IN COMPLIANCE WITH THE POST OFFICE INLAND LETTER POST SCHEME. The sender must also sign and date the package in the space provided. Information concerning the sample (data forms, letters and descriptive information) should be taped to the outside of the secondary container. A dentist sending a pathological specimen through the post without complying with the above requirements may be liable to prosecution. Pathological specimens containing Hazard Group 4 pathogens should not be sent through the post. This group includes any organism that causes severe human disease and is a serious hazard to laboratory workers. It may present a high risk of spread in the community and there is usually no effective prophylaxis or treatment available. Pressure systems All those who use autoclaves within the practice should be thoroughly trained in their use (Provision and Use of Work Equipment Regulations 1998). The Pressure Systems Safety Regulations 2000 were introduced to prevent the risk of serious injury from the release of stored energy as a result of a pressure system failure. All autoclaves and air-receivers with a capacity of more than 250 Bar-litres must comply with the Regulations. Before an autoclave or air-receiver is used, a competent person should draw up a written scheme of

examination detailing the periodic examination of the vessel. The written scheme must be regularly reviewed. Records must be kept to show that the periodic examinations have been carried out in line with the written scheme. The maximum intervals for inspection are 14 months for autoclaves and 26 months for air receivers. Inspection can be arranged through BDA Insurance Services (tel: 0870 241 1761). Examination for safety reasons is not equivalent to servicing and performance testing, which should be carried out in accordance with the manufacturers instruction. Where the Regulations do not apply, for example small capacity air receivers, regular maintenance is still essential. A competent person is defined as someone who has practical and theoretical knowledge and actual experience of the type of machinery or plant to be examined, able to detect defects or weaknesses and to assess their importance in relation to the strength or function of the particular vessel. The Health and Safety Executive has produced guidance to help users of autoclaves comply with the law. Safety at autoclaves (Guidance Note PM73, second edition), available from HSE Books (tel: 01787 881165), describes the hazards specific to autoclaves because of the need to open them frequently during the sterilisation process to load and unload the contents and the safeguards that should be in place. The hazards identified include: explosive displacement of a door if the door of an autoclave is not properly secured whilst under internal pressure, it may be displaced allowing an explosive release of stored energy violent opening of the door due to residual pressure at the end of a process cycle scalding explosion of sealed glass containers containing liquids. The following safeguards should be in place: the design should meet relevant

British Standards a safety valve to prevent overpressurisation, a reducing valve to prevent the maximum pressure being exceeded, an isolating or stop valve in the inlet line, a pressure indicator and a drainage system the maximum allowable working pressure should be clearly marked on the autoclave autoclaves with quick opening doors should not be capable of being pressurised unless the door is completely closed, the securing mechanism fully engaged and the chamber sealed. Maintenance checks, following the manufacturers instruction, should be carried out at regular intervals by an experienced person properly trained and competent to recognise defects.

Protective equipment Employers must provide protective equipment where it is necessary to ensure safe systems of work (Personal Protective Equipment at Work Regulations 1992). Employees cannot be charged for supplying, cleaning, repairing or replacing protective equipment, including protective clothing. Personal protective equipment (PPE) made or sold in the UK must carry the CE mark to indicate that it has been satisfactorily type-examined by an Approved Body. In dentistry, protective clothing can minimise the risks at work but it is not a substitute for more basic safety measures. Gloves: Medical gloves for single use (to BS EN 455, parts 1 and 2) should be worn for all clinical procedures as they protect against contact with blood, saliva and other tissue fluids. Heavy-duty gloves give protection against burns or skin irritation when handling disinfecting agents, domestic cleaning agents, cleaning solvents and radiographic processing chemicals. Damaged gloves do not provide adequate protection and should be replaced and not kept in use. Care should be taken when choosing latex gloves. Latex is covered by the COSHH Regulations, which restricts
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the use of both powdered latex gloves and those with a high leachable protein content as far as is reasonably practicable. Further advice is contained in the Medicines and Healthcare Products Regulatory Agencys publication Latex sensitisation in the health care setting (use of latex gloves) (DB 9601) available on request from the MHRA (tel: 020 7972 8000), and the HSE publication Latex and you. Eye protection should be worn by those working in close proximity to the patient during treatment. Eyewear should have full lenses and side protection; half lenses do not give enough protection against splatter and projectiles from the mouth, for example, tooth and amalgam particles. Protective clothing should be worn only in the surgery or laboratory and not taken into eating areas. Uniforms should avoid any features that could collect mercury or catch equipment. Contaminated clothing should be washed in a washing machine using a biological detergent and a hot wash cycle (at least 65C). Suitable shoes can protect against spillage, irritants and other substances. Radiation hazards Your requirements under the Ionising Radiations Regulations 1999 and the Ionising Radiation (Medical Exposure) Regulations 2000 are consolidated in the BDAs advice sheet on radiation in dentistry (A11) and includes: the various appointments that you need to make within the practice risks from dental radiology current radiation protection legislation education and training requirements for those involved in the taking or processing of radiographs patient selection and clinical justification diagnostic interpretation of the radiograph equipment for dental radiology quality assurance.

provide adequate information, instruction and training for all staff

Local Rules should be kept with each x-ray machine and should detail the working practices needed to comply with the Regulations. To comply, you should: notify the Health and Safety Executive of the use of radiation within the practice appoint an external Radiation Protection Adviser (RPA) appoint a suitably qualified and trained person within the practice to act as the Radiation Protection Supervisor (RPS). Where possible a deputy RPS should also be appointed to take responsibility when necessary ensure that equipment meets all appropriate standards and is serviced and maintained according to the manufacturers recommendations and the RPAs guidance ensure routine tests are carried out every three years by a competent authority such as the National Radiological Protection Board or the medical physics department of your local hospital provide local rules which must contain the name of the RPA, RPS, a description of the controlled area and any local requirements. Model Local Rules can be found in the the BDAs Practice Compendium provide adequate information,

instruction and training for all staff personal monitoring for staff is required if individual workload exceeds 100 intra-oral or 50 panoral films per week. A postal monitoring service is provided by the NRPB provide a contingency plan to specify actions to be followed in the event of equipment malfunction.

Risk assessment Employers are required to assess the risks to those in the workplace and any others who may be affected (Management of Health and Safety at Work Regulations 1999). Employers with five or more employees (including self-employed associates and PCDs) must record the significant findings of this assessment. Further information on risk assessment can be found in the BDAs advice sheet on risk assessment in dentistry (A5) and the Clinical Governance Kit. A risk assessment is nothing more than a careful examination of what in your workplace could cause people harm, so that you can weigh up whether you have taken enough precautions or need to do more. The following step-by-step approach will help you carry out a risk assessment within your practice.

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Step 1: look for the hazards. Look around the practice for hazards and ask other members of the practice if they are aware of any hazards. Manufacturers instructions (for equipment and products) and material safety data sheets (for hazardous substances) are important in helping to identify hazards and risks. Accidents and ill-health records can also be useful. Step 2: decide who might be harmed and how. Consider those who may not be in the practice all the time, for example, cleaners, contractors and those who may share your premises. Is there a possibility that they could be affected by your activities? Give particular consideration to children and ensure they do not have access to hazardous substances, sharps containers, clinical waste etc. Step 3: evaluate the risks arising from the hazards and decide whether existing precautions are adequate or if more should be done. Even after all precautions have been taken, some risks may remain. You have to decide for each significant hazard whether the risk is high, medium or low. Have you done everything that is required by law? For example, have you assessed all the hazardous substances? Are generally accepted standards in place? You must do whatever is reasonably practicable to keep your workplace safe by minimising all risks. If you find that something needs to be done, ask yourself whether you can eliminate the risk altogether or, if not, what you can do to control the risk so that harm is unlikely. Step 4: record your findings. This means writing down the more significant findings and recording your most important conclusions. For example, portable electrical appliances visual inspection of equipment cable and plug, internal wiring and fuse checked; all found sound. You do not have to show how you did the assessment; you only have to show that: a proper check was made you asked who might be affected

you dealt with all the obvious significant hazards the precautions are reasonable and the remaining risk is low.

Further information on carrying out your COSHH assessment can be found in the BDAs advice sheet on risk assessment in dentistry (A5) and the Clinical Governance Kit. You may have already covered some aspects of your COSHH assessment in your general risk assessment. It is not necessary to duplicate assessments, so where you have already addressed a risk and identified how to reduce or control it, simply cross-reference your COSHH assessment with the practice risk assessment or combine the assessments. Exposure limits: there are two types of occupational exposure limits for hazardous substances; occupational exposure standards (OESs) and maximum exposure limits (MELs). MELs are set for substances for which no safe level of exposure can be identified or for substances for which safe levels may exist but difficult to achieve in practice. Exposure to these substances has or is liable to have serious health implications of workers for example, may cause cancer or occupational asthma. Where the material safety data sheet provided by the manufacturer refers to an OES or MEL, dentists are obliged to meet the requirements of

To make things easier, you can refer to other assessments in the practice such as your health and safety policy statement, COSHH assessments and manufacturers instructions these may already list hazards and precautions that you need to be aware of. Step 5: review your assessment from time to time. Sooner or later you will add new equipment or substances to the practice, which could introduce new hazards. If there is a significant change, you should add to the assessment to take account of these new hazards. In your risk assessment, you must assess the hazards and risks arising from work with display screen equipment, manual handling, hazardous substances, young workers and pregnant or nursing staff. You will also need to consider the risk of fire in the workplace and assess whether the existing precautions are adequate. Risk assessment - hazardous substances Employers must ensure that exposure of workers to hazardous substances is either prevented or, where this is not reasonably practicable, adequately controlled (Control of Substances Hazardous to Health Regulations 2002 (COSHH)). When carrying out your COSHH assessment, you need to identify the hazardous substances in the practice decide who might harmed and how assess the risks associated with their use carry out any necessary health surveillance prevent or control the risk ensure staff are aware of the risks and trained to handle hazardous substances carefully make a record of your assessment and update it regularly

You must do whatever is reasonably practicable to keep your workplace safe

corrosive

harmful

irritant

toxic

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those levels in order to ensure a safe working environment for their employees. Few substances used in dentistry are assigned a MEL. One example is glutaraldehyde, which has recently been set a MEL of 0.05ppm for both long-term and short-term exposures. Risk assessment - pregnant and nursing mothers You must take particular account of risks to new and expectant mothers. If you cannot avoid a risk by other means, you will need to make changes to working conditions or hours or offer suitable alternative work. If this is not possible, the employee should be given paid leave for as long as necessary to protect her health or safety or that of her child. Your risk assessment may show there is a substance or work process in your practice that could damage the health or safety of new or expectant mothers or their children. You need to bear in mind that there could be different risks depending on whether workers are pregnant, have recently given birth or are breast-feeding. For example, mercury is a very toxic substance and your risk assessment might reveal that a pregnant dental nurse is at risk from mercury vapour whilst chairside assisting. You might decide to seek additional biological monitoring for mercury at regular intervals during the pregnancy to ensure that she is not exposed to levels of mercury in excess of the occupational exposure standard. Anxieties that the member of staff has about aspects of her work must be taken into account and, wherever possible, work practices altered to alleviate concerns. A model risk assessment for pregnant and nursing mothers is available in the BDA Practice Compendium, which you can adapt to suit your individual circumstances. Risk assessment young people Young workers may be particularly at risk from workplace hazards because of their lack of awareness of existing potential risks, immaturity or
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inexperience. A young person is defined as a person who has not reached the age of 18 and so will include work experience students as well as trainee dental nurses. Before employing young people, you must carry out a risk assessment to identify any specific risks that they might face: the inexperience and immaturity of young people their lack of awareness of risks to their health and safety the fitting out and layout of the practice and surgery exposure to biological, chemical or physical agents use and handling of work equipment what the work involves the processes and activities to be undertaken any health and safety training given or intended to be given. With work experience students who are under 16 years, you will have to inform the parents or legal guardian of the findings of your risk assessment. The BDAs advice sheet on risk assessment (A5) provides further information. A model risk assessment for trainees and young people at work is available in the BDA Practice Compendium. Safety signs Employers are required to use a safety sign wherever a hazard exists that cannot be adequately controlled by any other means (The Health and Safety (Safety Signs and Signals) Regulations 1996). When everything else has been done to remove the hazard, safety signs should be used to reduce the risk further. Safety signs include acoustic signals, illuminated signs, marking of pipework and containers and hand signals. All safety signs are required to contain a pictogram (symbol) as part of their design. There are a few exceptions to this rule. Fire signs such as Fire Door Keep Shut do not contain a symbol as part of design and so technically do not follow the pattern prescribed by the Regulations. It is unlikely, however,

that the use of these signs will be precluded. Dentists should have, as a minimum, the following safety signs within the practice: Fire safety signs these signs provide safety information on escape routes, emergency exits, location of fire fighting equipment and a means of giving warning in the event of a fire (illuminated signs and acoustic signals are included) First aid where first-aid facilities are located and the designated person Radiation adequate warning signals when the equipment is in use. Stress Work related stress is an increasing concern for employers and is currently the second most common cause of ill health associated with work. Stress can be defined as the adverse reaction people have to excessive pressure or other types of demand placed on them. Potential causes of work-related stress include: organisational culture e.g. poor communication, name and blame attitude physical and psychological demands associated with the job level of control over the job relationships with managers, peers, etc management of change at work individuals not knowing what their role is, what their work entails or what their responsibilities are lack of managerial and/or peer support. Stress sufferers often demonstrate well-recognised physiological symptoms, which include headaches, aching muscles particularly neck and shoulders, rashes and increased sweating. Common psychological and behavioural signs include: depression or general negative outlook increased anxiousness increased irritability

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lack of concentration loss of aptitude poor work performance increased sickness absence inability to cope with normal tasks poor time keeping increased intake of alcohol, caffeine, nicotine etc.

Personal protective equipment is regarded as a last resort. Waste disposal

Stress related complaints must be treated seriously and fully investigated. Successful stress management will depend on good communication amongst staff, identifying the reasons for the stress and then developing a strategy to deal with the causes. Further information on work related stress can be found in the HSE publication HSG 218 Tackling work related stress and on the HSE website, (www.hse.gov.uk/stress/index.htm) or from the HSE Infoline (tel: 0870 154 5500). Ventilation Air turbines, ultrasonic scalers, airwater syringes and dental lathes can produce splatter reaching a distance of seven feet and an aerosol containing tooth particles, bacteria, fungi and possibly viruses and oil. Instruments on the bracket table can easily become contaminated. Aerosol inhalation may lead to chronic coughs and bronchitis and can be harmful to the eyes. Risks are considerably reduced by good ventilation and the use of high-speed suction, face masks and glasses. Enclosed workplaces must be ventilated with sufficient fresh or purified air; an open window will provide sufficient ventilation in most cases. Where ventilation systems are used, the fresh air supply rate should not fall below 5-8 litres per second per occupant but the means of ventilation should not create uncomfortable draughts. Recycling air conditioning systems are not recommended. Where exposure to a hazardous substance cannot be prevented, it should be controlled by other means. Local exhaust ventilation is one of the most common and effective methods of control available.

Stress sufferers often demonstrate wellrecognised physiological symptoms

Dentists, as producers of nondomestic waste, are required to sort their waste, store it safely and securely in an appropriate container and arrange for its disposal (Environmental Protection Act 1990). You will also need to maintain records and have the relevant documentation available (transfer notes, for example) to demonstrate compliance (Environmental Protection (Duty of Care) Regulations 1991). All waste from the practice should be segregated into clinical and nonclinical waste. If waste is mixed indiscriminately the entire load will have to be regarded as clinical waste and disposed of by the more expensive hazardous waste disposal method. Clinical waste is waste that is contaminated with blood, saliva and other body fluids and may prove hazardous to any person coming into contact with it. Clinical waste sacks must be no more than three-quarters full, have the air gently squeezed out to avoid bursting when handled, be labelled and tied at the neck, not knotted. Sharps waste (needles and scalpel blades) must be sealed in UN type approved puncture proof containers (to BS7320), which must be labelled before disposal. Sharps containers should be disposed of when no more than two-thirds full. Clinical waste should be disposed of by high temperature incineration, or other disposal facility licensed to handle it. Only someone registered to carry clinical and non-clinical waste should collect it from the practice. When waste is transferred, a written description of the waste must be transferred with it. In addition, a transfer note must be completed and copies kept by both parties. The following information must be included in the transfer note: identification of the waste whether it is loose or in a container

the kind of container (if applicable) the time, date and place of transfer the name and address of the transferor and transferee whether the transferor is the producer or importer of the waste which (if any) authorised transport purpose applies which categories best describe the transferor and transferee, eg waste management licence holder, registered carrier etc. the licence number of either or both parties and the council that issued it.

Repeated transfers of the same kind of waste between the same parties can be covered by one transfer note for up to one year. Both parties must keep copies of the transfer note for two years since either party may have to prove in court where the waste came from and what happened to it. Dentists are now required to add the appropriate European Waste Catalogue (EWC) code to the description of the waste on the transfer note. Prescribed medicines and waste classified as irritant, harmful, toxic, carcinogenic or corrosive are regarded as special waste (Special Waste Regulations 1996). Local anaesthetic solution is a prescribed medicine so partially discharged cartridges must be disposed of as special waste. If these are disposed of via the sharps box, then the container must be disposed of as special waste. Fully discharged cartridges are not regarded as special waste. Disposal of special waste is subject to additional controls: consignment notes must be used at each stage of the disposal process and signed at each transfer of the waste from source to disposal site. Consignment notices must be kept for three years. An additional levy is also payable by the producer of the waste. Radiographic developer and fixer are classified as special waste. These solutions must not be
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European waste catalogue codes for dental waste Waste types Sharps Box If the sharps box is used to dispose of other wastes such as LA cartridges (fully discharged) or extracted teeth Healthcare medicines (POMs and partially discharged LA cartridges)* Extracted teeth (no amalgam present) Yellow Sacks Clinical waste (contaminated swabs, gloves etc.) Female Hygiene Waste Amalgam Waste Amalgam waste Extracted teeth containing amalgam General Waste Paper and cardboard Biodegradable kitchen waste Packaging material Radiographic Solutions* Developer Fixer
*denotes Special Waste that will require a consignment note

Code

potentially hazardous situations, especially if the waterlines have become contaminated with Legionella, for example. The following precautions may help reduce or eliminate the problem of contaminated dental unit waterlines: the ultrasonic scaler, triple syringe and handpiece should be supplied by bottled water (clean water system). The manufacturers recommendations on decontamination and disinfection of the bottled water system must be followed closely effective anti-retraction systems should be installed sterile water should be used where surgical flaps or other surgical access into body cavities is anticipated the manufacturers recommendations on decontamination and disinfection of interposed cisterns must be followed rigorously. If you suspect that a waterline has become contaminated and the recommended decontamination and disinfection process is ineffective, advice should be sought from the consultant microbiologist of a local hospital (or dental hospital) or the Health Protection Agency. The BDAs advice note on water supplies to dental practice gives more information on how to comply with the requirements of the Regulations. Welfare arrangements You must ensure the welfare at work of all your employees (Workplace (Health, Safety and Welfare) Regulations 1992).

18 01 01

18 01 09 18 01 02 18 01 04

18 01 04 18 01 10

20 01 01 20 01 08 15 01 06

09 01 01 09 01 04

discharged to sewer and dentists are advised to seek the services of a waste collection agency licensed to collect and dispose of chemical waste. Waste amalgam is to be reclassified as special waste, which will make its disposal more controlled. At present, an authorised person should collect it and a transfer note completed with a written description of the waste. It should not be sent through the post. Water supplies Mains supplied water services must be protected from contamination by backsiphonage (The Water Supply (Water Fittings) Regulations 1999). The level of protection required depends upon the risk posed. The presence of blood and saliva in waste from the dental surgery requires the highest level of protection. Depending on your individual circumstances, a Type AA, AB or AUK1 air gap may be needed, but you should seek further advice from your local water company.
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Dental equipment requiring an air gap for protection against backsiphonage includes the dental spittoon, the delivery system (the dental handpiece, three-in-one syringe and ultrasonic scaler), wet-line suction apparatus and automatic radiographic processors. It is possible that an interposed cistern will be the most straightforward means of isolating the equipment from the mains water supply. An interposed cistern may, however, result in loss of water pressure and a pressurised cistern may need to be installed. Manufacturers of dental equipment are aware of the requirements of the Regulations and provide equipment with an integral air gap; you will need to check this with the manufacturer. As a result of water being stored in an interposed cistern, biofilms of micro-organisms and their products can develop and contaminate the associated dental water lines. Aerosolisation of contaminated water can result in

Working environment Lighting should be sufficient to enable people to work safely and without eyestrain. Where necessary, local lighting should be provided at individual workstations.

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Temperature. The workplace should be reasonably comfortable without the need for special clothing. The temperature should normally be at least 16C and thermometers must be available to check. There is no maximum temperature but you should remember the general duty for you to provide a safe place of work and excessive heat may adversely affect employees. Ventilation. Windows will generally provide sufficient ventilation. Where additional ventilation is required, mechanical systems should be provided. Room dimensions. Workrooms should have enough free space to allow people to move around with ease. As a guide, the total volume of the room, when empty, divided by the number of people working in it should be at least 11m3; more if much of the room is taken up by furniture. Workstations should be arranged so that each task can be carried out safely and comfortably. Seating should provide support to the lower back and be appropriate for the task.

Doors and gates should have a transparent panel unless they are low enough to see over.

Housekeeping Maintenance of workplace and equipment. Both should be in good working order and good repair. Equipment should be regularly maintained (with records). Cleanliness throughout the practice is essential and includes floors, walls and ceilings. Cleaning should not present a health or safety risk.

Facilities Toilets and washing facilities should be sufficient to allow everyone in the practice to use them without delay. The table shows the minimum number of toilets that should be provided. Separate male and female toilets should normally be provided unless the toilet is in a separate room and the door can be secured from the inside. Toilet paper should also be provided and where females are employed there should be a suitable means for disposing of sanitary dressings. Changing and storing clothing. A changing room should be provided for workers who change into special clothing. Work clothing and personal clothing should be stored in a well-ventilated place where it can dry out if necessary. Effective measures should be taken to provide security of clothing. Rest areas where staff can relax and eat their meals at work should be provided. No smoking areas should be made available.

Safety Floor surfaces should be free from holes, unevenness or slipperiness, which could cause a person to trip, slip or fall, or to drop anything being carried. Windows and skylights should be able to be opened, closed and cleaned from the inside (safely). Glazed doors and partitions should be made of a safety material or be protected against breakage, for example, by obvious marking.

Minimum number of toilets Employees present at any one time 1 to 5 6 to 25 26 to 50 Number of toilets 1 2 3

If patients also use the toilets provided for staff, it may be necessary to increase the number of toilets so that staff can use the facilities without undue delay

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Contact details
Useful addresses HSE Regional offices can be located by calling the HSE InfoLine on 0870 154 5500 HSE Books PO Box 1999 SUDBURY Suffolk CO10 6FS Tel: 01787 881165 Fax: 01787 313995 BDA Insurance Services Lloyd & Whyte (Insurance Brokers) Ltd Wessex Lodge 11-13 Billetfield TAUNTON Somerset TA1 3BR Tel: 0870 241 1761 Fax: 01823 335157 Medicines and Healthcare Products Regulatory Agency Hannibal House Elephant and Castle London SE1 6TQ Tel: 020 7972 8000 Fax: 020 7972 8108 National Radiological Protection Board (NRPB) Northern Centre Hospital Lane COOKRIDGE Leeds LS16 6RW Tel: 01132 300232 UK Mercury Screening Service Sheffield Analytical Services PO Box 187 137 Portobello Street SHEFFIELD S1 4DS Tel: 0114 290 0521

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Health and Safety Checklist Comment Management of health and safety Is the health and safety poster on display or a leaflet provided? Is the Certificate of Employers Liability Insurance displayed? Is there a safety policy for the practice? Has it been signed by employer? Has the safety policy been made available to all staff? Accidents Are the contact details of the local HSE available? Are report forms F2508 and F2508A accessible? Is there an accident book in the practice? Are the MHRA contact details available to report adverse incidents? Anaesthetic gases Are the rooms used well ventilated? Is active scavenging used? Is the equipment in good working order and regularly serviced? Have staff received training on the control measures in place to keep exposure to a minimum? Display screen equipment Have users been identified? Have they received the appropriate information, instruction and training? Has a risk assessment been carried out on each user and their workstation? Have the assessments been documented? Have users been given eyesight tests when requested? Has eyewear been provided if required? Has work been planned to allow for breaks or changes of activity? Electricity Is all portable electrical equipment regularly visually inspected? Are there records of these visual checks? Is electrical equipment periodically checked by a competent person?

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Health and Safety Checklist Comment Are records kept of these inspections? Have staff been trained in the safe use of electrical equipment? Fire precautions Is a fire certificate required? Has a fire risk assessment been carried out and shown to staff? Are fire detection measures in place? Is adequate fire fighting equipment available? Are all staff trained to use fire fighting equipment and know what to do in the event of a fire? Is the fire safety equipment regularly checked and maintained? First-aid / medical emergencies Is there a trained first-aider or appointed person in the practice at all times? Does everyone know where the first-aid box is kept? Is it fully stocked? Are all members of the dental team trained in CPR? Has training been undertaken in the last 12 months? Is the appropriate emergency equipment available? Are emergency drugs and a portable supply of oxygen readily available? Lasers Are local rules and warning signs displayed? Is equipment regularly maintained and records kept? Have users been appropriately trained? Manual handling Has a manual handling assessment been carried out? Are staff trained in good handling techniques? Where risks have been identified, have control measures been introduced? Medicine storage Are medicines stored according to manufacturers instructions?

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Health and safety law for dental practice

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Health and Safety Checklist Comment Are medicines kept in a locked cupboard with restricted access? Are stocks regularly checked and out dated stock disposed of? Are records kept of supplies and suppliers? Mercury Have clinical staff been informed of the hazards? Do clinical staff receive regular biological monitoring? Do staff know what to do in the event of a spillage? Is a fully stocked mercury spillage kit available? Are the surgeries adequately ventilated? Are floors and work-surfaces impervious and smooth? Are staff trained in the use of the amalgamator? Pathological specimens Is first class or special delivery used when sending pathological specimens? Do packages comply with UN 602 requirements? Are outer packages labelled PACKED IN COMPLIANCE WITH THE POST OFFICE INLAND LETTER POST SCHEME? Pregnant and nursing mothers Has a risk assessment been carried out for pregnant and nursing members of staff? Have work practices been altered to eliminate health risks where appropriate? Are any anxieties about work being addressed? Pressure systems autoclaves and air-receivers Have staff been trained in how to use the equipment? Is there a written scheme of examination for each autoclave and air-receiver, detailing the extent and frequency of examination? Do you have records of these examinations and any work required? Is the equipment serviced in line with the manufacturers instructions? Do you have records of servicing?

BDA March 2004

bda advice sheet A3

Health and safety law for dental practice

25

Health and Safety Checklist Comment Radiation Have you informed HSE that radiation equipment is being used? Has a RPS and RPA been appointed? Has the RPA carried out a risk assessment? Has a controlled area been designated for each piece of equipment? Are there Local Rules for each piece of equipment? Is the radiation equipment maintained and serviced? Are there records? Are contingency plans in place in case of accidental over-exposure or malfunction of the equipment? Have staff been trained for the tasks they are required to do? Are there records of the training provided? Has a clinical audit been carried out within the last 12 months? Risk assessment Have the hazards in the workplace been identified? Have employees at risk been identified? Have adequate controls been put in place to remove or reduce the risks? Has the risk assessment been recorded and dated? Have staff been informed of the outcome of the assessments? Are the assessments updated regularly? Have you carried out separate assessments for any young workers and pregnant staff? Risk assessment hazardous substances Have you identified all hazardous substances used in the practice? Have you considered biological hazards? Have you assessed the risks to employees? Are the control measures adequate or does more need to be done? Have you considered the need for health surveillance (with mercury use, for example)? Have the assessments been documented and dated? Have you made staff aware of the risks involved with the hazardous substances identified and trained them to use these substances safely? Are the assessments reviewed on a regular basis?
BDA March 2004

26

Health and safety law for dental practice

bda advice sheet A3

Health and Safety Checklist Comment Safety signs Are fire fighting equipment and escape routes clearly marked? Are the first-aid facilities clearly marked and the designated person identified? Do all safety signs contain a pictogram? Does all radiographic equipment have warning signals to indicate when equipment is in use? Waste Is waste segregated into non-clinical, clinical and special waste prior to disposal? Is waste collected by someone registered to carry it? Are waste transfer notes / consignment notes completed and signed by both parties? Do you have waste transfer notes for the last 2 years and consignment notes for the last 3 years? Are the appropriate EWC codes inserted on the transfer note?

Welfare Is there adequate ventilation in the practice? Is a suitable working temperature maintained? Is the lighting sufficient to carryout all work activities? Are there sufficient toilets for employees? Are sanitary disposal facilities provided in toilets used by females? Are suitable rest and eating facilities provided? Are floors free from tripping hazards?

BDA March 2004

British Dental Association 64 Wimpole Street London W1G 8YS Tel: 020 7563 4563 Fax: 020 7487 5232 E-mail: enquiries@bda.org.uk BDA March 2004