Liability
Health & Safety Best Practices for Dental Offices Protect your practice, productivity and the well-being of your dental team. Reduce the risk of workplace injuries by taking specific, consistent precautions and educating your staff on required safety protocols. Learn and share guidance on sharps incidents, ergonomics, accident reporting and more. continued on page 2
IN THIS ISSUE Needlestick injuries 2 Bloodborne pathogen protocol flowcharts 3 Ergonomics 4 Emergency kits, plans and communication 6 Advice Line Q&A 7
Vol. 3 2020
Practice owners understand that their responsibilities extend far beyond protecting the health of their patients. As illustrated by the COVID-19 pandemic, employers continue to learn firsthand what can be fluid recommendations and requirements of their ever-changing duties to keep their employees and the public safe. While dental offices are generally considered to be safe workplaces, they are not without risk. From needlestick injuries to carpal tunnel syndrome, dental practice employees can face exposure to numerous workplace hazards in the everyday workplace, not to mention in emergency situations. Under federal law, employees have the right to perform their duties under working conditions that do not pose a risk of serious harm. They also have a right to receive information and training on workplace hazards, how to avoid potential hazards and how to report injuries or threats to their health without retaliation. The federal Occupational Safety and Health Administration (OSHA) and some states have legal requirements for employers to create and maintain safe workplaces. OSHA maintains a webpage dedicated to dentistry, and many general industry standards also apply to dental offices, including those that address bloodborne pathogens and biological agents, ergonomic hazards and exposure to toxic chemicals.
Needlestick injuries The Dentists Insurance Company handles a wide range of workers’ compensation claims related to workplace injuries, including everything from slip-and-fall accidents to strained muscles. But by far the most common type of injuries in the dental 2
office are cuts, punctures, scrapes and needlestick injuries. In fact, more than 70% of all injury claims in 2019 fell into this category, according to TDIC data.
From needlestick injuries to carpal tunnel syndrome, dental practice employees can face exposure to numerous workplace hazards. Needlestick injuries are one of the greatest occupational hazards in the dental office. Most of these injuries occur when breaking down instrument trays following a procedure. In many cases, the employee was removing the anesthetic carpule or removing the needle from the syringe when the cap slipped off the needle and caused the puncture. Needlestick injuries can put health care workers at risk of exposure to bloodborne pathogens, including hepatitis B, hepatitis C and HIV. According to the Centers for Disease Control and Prevention (CDC), the risk for infection after exposure is quite low, hovering around 1.8% for HCV and virtually zero for those who have received the HBV vaccine. For HIV, the average risk is about 0.3% after a needlestick injury or cut, according to the CDC. In one case reported to TDIC, a full-time dental assistant had just completed assisting a dentist with a root canal procedure. In a rush to prepare the operatory for the next
patient, the assistant failed to notice that the needle was not capped and she punctured her right thumb with the needle. She reported the incident to the dentist. The dentist called TDIC’s Risk Management Advice Line for guidance on handling the incident. The analyst advised the dentist that wounds that have been in contact with blood or bodily fluids should be washed with soap and water. The analyst also reminded the dentist to properly document the needlestick incident in a sharps injury log, which is required by law in most jurisdictions. The dentist inquired if it would be acceptable to contact the source patient and request that she undergo testing. Additionally, he inquired about his responsibility covering any cost associated with patient testing. The analyst advised the dentist that it is a best practice to send the source patient for testing and reassured him that TDIC covers source testing under TDIC’s Professional & Dental Business Liability policy. Should a sharps injury occur, practice owners are responsible for managing the exposure. In some cases, post-exposure treatment may be recommended. TDIC advises practice owners to have a post-exposure plan in place and to train staff on the plan and its implementation. The plan should include the following: n Immediate reporting to the dentist of
a contaminated sharps injury or any exposure to blood or saliva.
n Forms documenting the exposure and, when necessary, employee or source patient refusal of medical evaluation or testing.
n In California, a preselected physician from the medical provider network
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(MPN, a referral list provided by the workers’ compensation carrier) who can evaluate the exposed dental professional within 24 hours.
n A sharps injury log, which includes
information about the injury, the type and brand of device, the work area where the exposure occurred and an explanation of how the injury occurred.
Contact your workers’ compensation carrier immediately following an incident for instructions on employee testing and source patient testing. Employers are required to pay for the employee’s evaluation; however, all workers’ compensation carriers, including TDIC, cover testing for employees in the event of a contaminated sharps injury.
Preventing needlestick injuries When it comes to sharps injuries, the best cure is preventing them from occurring in the first place. The CDC offers the following recommendations in its downloadable brochure titled Preventing Needlestick Injuries in Health Care Settings: n Dispose of used needles and other sharps in appropriate sharps disposal containers.
n Use appropriate barriers such as gloves and personal protective equipment (PPE).
Bloodborne pathogen protocols Whether a needlestick injury or another type of cut, puncture or scrape, the following protocols established by
the CDC and OSHA can greatly reduce the risk of post-exposure infection. Protocols for employees are illustrated below and protocols for employers are on the following page.
Employee responsibilities Wash the injury site with soap and water. If the exposed area is the face, flush with water or use an eyewash station.
Report the injury to the employer and obtain the necessary state-mandated forms to file a workers’ compensation claim.
Seek medical treatment immediately. The medical care may be self-guided or employer-guided. Note: employees have the right to refuse post-exposure treatment.
n Use devices with safety features,
such as engineered sharps injury protection (ESIP).
n Provide education and training to employees on preventing injury.
Provide work status reports to the employer and discuss accommodations if work restrictions are provided.
n Avoid the use of needles when effective alternatives are available.
n Establish procedures and encourage reporting for sharps-related injuries.
In addition, dental employees should avoid bending or breaking needles before disposal, passing a syringe with an unsheathed needle and recapping needles prior to disposal.
Continue to seek treatment until testing has been completed and you are discharged from medical care.
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Ergonomics
Employer responsibilities Depending on state or federal OSHA regulations, the employer may be required to complete an exposure report for the medical provider and/or a sharps injury log.
Contact the workers’ compensation carrier to file a claim. Notify the carrier if the employee refuses treatment. Discuss the possibility of source patient testing, which may be covered under your policy.
Verify with the carrier if there are any other state or federally regulated OSHA documentation or notification requirements.
Inform the employee of the need to provide a work status report after each medical visit. Discuss accommodations if work restrictions are provided.
Review office safety procedures. Make updates if necessary and provide employees with training on the bloodborne pathogen protocol.
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Continuous trauma is the second most common claim. According to TDIC, more than 600 such claims have been made since 2015. Continuous trauma, also known as cumulative trauma, is injury caused by repetitive motion or overextension for an extended period of time. These types of injuries range from impingement syndrome and bursitis to lower back injury and trigger finger. In the dental office, they are almost exclusively tendon and nerve disorders, such as tendonitis and carpal tunnel syndrome. TDIC reports a case in which an experienced registered dental hygienist began noticing she was suffering neck pain toward the end of each shift. The practice owner called the Risk Management Advice Line for assistance on how to address the situation. The dentist indicated that the hygienist did not regularly sharpen the scalers that she was using during scaling and root planing. The analyst discussed with the dentist that using dull instruments requires additional physical force and repetitive motion. In addition, the analyst advised the dentist to encourage employees to get up and stretch between appointments and to take necessary breaks throughout the day. This reduces fatigue and strain and allows increased blood supply throughout the body. While working, the hygienist should keep her body in a neutral position, meaning a position that puts minimal stress on the musculoskeletal system. The analyst reminded the dentist that using dull instruments requires additional physical force and repetitive motion, and the analyst advised the dentist to discuss these best practices with the employee and to continued on page 6
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Understand the role of good communication, documentation, patient selection and case management in lessening risk. Plus, earn 3.0 ADA CERP credits upon course completion.* See details and register at tdicinsurance.com/seminars.
* Important information about your 5% Professional Liability premium discount: TDIC policyholders who complete a seminar or eLearning option will receive a twoyear, 5% Professional Liability premium discount effective their next policy renewal. To obtain the two-year, 5% Professional Liability premium discount, Arizona, California and Nevada dentists must successfully complete the seminar by April 23, 2021. Alaska, Hawaii, Illinois, Minnesota, New Jersey, North Dakota and Pennsylvania dentists must successfully complete the seminar by October 29, 2021. Any eLearning tests received after the deadline will not be eligible for the discount. Non-policyholders who complete a seminar or eLearning option and are accepted for TDIC coverage will also be eligible for this discount.
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inform her of her rights to file a workers’ compensation claim.
n The wrists should be kept in a neutral
The best defense against continuous trauma injuries is ergonomics. Although not required in all states, having an ergonomics/repetitive motion injury prevention plan in place is a good practice to minimize risks and keep employees healthy.
approximately a 90-degree angle.
Ergonomics programs should consist of a worksite evaluation by a certified ergonomist to look for actions, processes or operations that may contribute to repetitive motion injuries. Other recommendations include the following: n Use neutral hand and body postures whenever possible.
n Use sharp, lightweight instruments to
reduce the required force and number of repetitions.
n Use properly fitted gloves, preferably
(straight) position.
compensation claim and obtain work status reports from the employee.
n The elbows and knees should be bent at
n Discuss the options for accommodation
n The top of the monitor should be at eye
n Document all discussions regarding
level or slightly below.
n Feet should be flat on the floor or on a footrest.
n Chairs and desks should be adjustable to the employee’s needs.
Part of a comprehensive ergonomics plan includes employee training on the risks and exposure associated with repetitive motion injuries, the symptoms and consequences of these types of injuries, the necessity of reporting injuries and the reporting procedure. Employees should also be trained in the methods used to reduce injury, such as adjusting their computer monitor and keeping a neutral position when doing tasks.
with the employee, if applicable.
workplace accommodations in the employee’s workers’ compensation file.
Other health and safety considerations First aid kits n OSHA requires employers to keep
emergency medical kits available should an employee be injured on the job. These kits should be inspected regularly to ensure they are well stocked and kept up to date. Some states, including California, require a doctor’s sign-off on medical emergency kits. They should include the following:
n Adhesive tape n Box of adhesive bandages n Directions for requesting emergency assistance
The best defense against continuous trauma injuries is ergonomics.
n Elastic wraps (two) n Gauze pads (at least 4 by 4 inches) n Gauze pads (two, at least 8 by
Other dental office ergonomic best practices include maintaining an erect posture, rather than bending or leaning over a patient; sitting, rather than standing, for all clinical procedures; working close to patients to avoid overextension; keeping feet flat on the floor or on a footrest; avoiding gripping instruments too tightly; and using equipment such as loupes and mirrors to improve visibility.
Reporting employee injuries
n Resuscitation equipment such as
For front office staff, office managers and those whose work is primarily done in front of a computer, the following is advised:
n Provide the applicable workers’
n The computer monitor and
n Remain in contact with the employee
left- and right-handed gloves.
n Spread out appointments that include heavy scaling work to allow muscles to rest.
n Lift heavy boxes or equipment with leg muscles and keep the back straight.
n Avoid lifting below the knee and above shoulder height.
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keyboard should be directly in front of the operator.
10 inches)
n Latex gloves n One blanket (minimum) n One package gauze roller bandage (at least 2 inches wide)
Should an employee complain of ongoing pain or report an acute injury related to their work, employers must follow protocols similar to those required with needlestick injuries. This includes the following: n Notify your workers’ compensation carrier of the injury immediately to determine where you can send the employee for medical care.
compensation claim forms to the employee within the required timeframe (typically, one working day after being made aware of the injury). throughout the life of their workers’
resuscitation bag, airway or pocket mask
n Scissors n Splint n Tweezers n Triangular bandages (two) n Wound cleaning agent such as sealed moistened towelettes
Hazard communication Dental office employees are at risk of occupational exposure to a variety of hazardous chemicals, and practice owners are required by law to recognize, control and prevent these risks. Dental practices can expose employees to beryllium, mercury, silica dust and waste
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anesthetic gases. Being aware of these hazards is the first step in mitigating injury, and employers are required to have a written plan describing how they communicate the hazards to employees.
Safe work practices. This includes proper lifting techniques, using proper safety equipment and training and use of autoclaves, among other safety practices.
Many states, including California, require employers to have written hazard communication plans in place. The plan should include, but are not limited to, a list of all hazardous substances in the workplace, a labeling program for these substances, a file of Safety Data Sheets (with pictograms) and protocols for employees to protect themselves. Part of such plans should also include safety trainings. More information can be found on OSHA’s Hazard Communication webpage and respective state occupational safety and health websites.
Protective equipment. This includes wearing protective equipment and training on the use of eyewash stations.
Office safety and emergency plans Dental offices are required to have written plans in place for general office safety, which should include checklists and training for employees. These should address the following: Safe workplace conditions. This includes keeping walkways and work areas clear of clutter and cords, keeping exits accessible and illuminated, grounding electrical equipment and other basic safety guidelines.
Many states, including California, require employers to have written hazard communication plans in place.
OSHA also requires most employers to implement emergency action plans. These plans outline the responsibilities of employees in the case of fire or other emergencies. They also provide guidance on fire prevention, emergency exits and hazardous waste disposal.
Training on emergency plans must be provided to all employees. While patient health is of paramount importance to dental professionals, ensuring the safety of employees is also a crucial component of practice ownership. Dental practices are not inherently dangerous, but like all workplaces, they do present risks. Taking precautions and educating staff on safety protocols as established by state and federal law not only keeps employees free from injury, it can protect you and your practice.
Questions and Answers TDIC’s Risk Management Advice Line helps dental professionals navigate difficult situations when dealing with potential claims from patient or employee situations. The real-world calls detailed below illustrate how analysts have helped callers this year. Q: As a specialist, what do I say to a patient who asks about the status of their treatment performed by the referring dentist?
A: Specialists often depend on
referrals from general dentists and other specialists for their patient base. This is generally a cooperative situation where patients receive quality dental care from all practitioners. However, there can be situations when the specialist suspects the patient has received substandard dental care from the referring dentist. It can be a challenge to navigate the situation without jeopardizing the relationship with the referring dentist. Consider a patient who presents to a periodontist for an evaluation. The periodontist notices open margins on three crowns. When asked, the patient
states she just had them done. Without further information, it is easy for the periodontist to assume the general dentist did an inferior job. However, unless the periodontist has seen all the prior records and radiographs and spoken with the referring dentist, there is no way to be sure exactly what led to the observed result. All dental professionals should avoid making statements that can be misinterpreted by patients. Often, what is intended to be conveyed is not what the patient hears. For example, if the specialist says, “these crowns don’t seem seated,” the patient’s interpretation may continued on page 9
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40 years and counting VIS IO N + F OC US + S T R E NG T H What does it mean to be built by dentists? In 1980, a small group of CDA members took action and founded The Dentists Insurance Company with a mission to protect only dentists. Since that time, TDIC has transformed from providing professional liability coverage to delivering comprehensive insurance and risk management solutions for a community of 24,000 policyholders in 15 states. Today, we still protect only dentists — with the same drive and dedication as our founders. Discover our dentist-led vision at tdicinsurance.com.
Protecting dentists. It’s all we do. 800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783 @TDICinsurance
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continued from page 7
vary from “your general dentist really messed up” to “these don’t look good.” These perceptions, however misguided, may jeopardize the relationship between the general dentist and patient as well as damage the professional relationship between the two dentists. Before discussing treatment concerns with the patient, talk to the general dentist. Tell the patient that you see some things you would like to discuss with the general dentist before you can recommend a treatment plan and that you will have your staff reschedule the treatment. Contact the general dentist and relay what you observed. It may be that another dentist did the restorations or the patient is noncompliant — for example, a heavy grinder who refuses to wear a nightguard. When legitimate treatment issues exist, discuss ways to address them. If the referring dentist is unreceptive, contact TDIC’s Risk Management Advice Line for situationspecific advice. It is important for the two dentists to know one another and trust each other’s dentistry. If an untoward event occurs during a referral appointment, the referring dentist may be vicariously liable. Agree to a preferred protocol for patient referrals. Specialists should receive a referral slip or letter clearly stating the purpose of the referral. Once the specialist examines the patient, send a written evaluation back to the referring dentist. If either dentist has questions or concerns about the referral or evaluation, they should reach out without delay. A referral slip doesn’t negate the independent duty to evaluate necessary patient care. TDIC has developed sample referral and evaluation result letters that are available at tdicinsurance. com. This way, the dentists involved are communicating and the patient
receives quality, consistent care. Patient referrals are the lifeblood of many specialty practices and should never conflict with one’s professional obligation. When suspecting substandard care, investigate the situation prior to making any judgments. There is likely more to the story than what is first assumed.
Specialists often depend on referrals from general dentists and other specialists for their patient base. This is generally a cooperative situation where patients receive quality dental care from all practitioners. Q. What is a reasonable and fair fee to charge patients who request their dental records? A: Some states allow dental practices to charge patients for the expenses incurred in photocopying records. The U.S. Department of Health and Human Services clarified its regulations in a guidance issued in 2016. The guidance made clear that the fee for access may include only the cost of:
n Labor to make the requested copy, whether in paper or electronic for
n Supplies such as paper or portable electronic media
n Postage when the patient requests the copy or summary be mailed
n Preparation of an explanation or
summary of the record if requested by the patient
All reasonable costs, not exceeding actual costs, incurred by the dental office to provide paper copies and digital files may be charged to the patient, but charges may not exceed specified legal limits. When determining the allowable costs for duplication of patient records, refer to fees set by state codes. The original patient record is the property of the dentist. However, the patient is entitled to the information it contains. Never release any part of the original patient record, including radiographs or models. Patients can request a copy for themselves or request that you forward a copy to another dentist or health care provider. Upon receipt of a written request from the patient or the patient’s representative, provide a copy of the complete dental record to the requestor. In the event the patient refuses to pay duplication fees, you are still obligated to provide copies of the patient’s records. You cannot withhold copies of patient records pending payment of an outstanding balance. It is important to establish reasonable conditions for transmitting records without discrimination against classes or categories of patients. Although you can charge for copies, consider carefully whether charging will inflame an already difficult situation. In addition, do not base your decision to charge for reproduction of records upon punitive, discriminatory or retaliatory reasons. Reference state-specific guidelines for record-keeping and record requests, and check with your state dental board for more information on allowable charges. 9
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Liability Lifeline is published by: The Dentists Insurance Company 1201 K Street, 17th Floor Sacramento, California 95814
©2019, The Dentists Insurance Company
Endorsed by: Alaska Dental Society California Dental Association Hawaii Dental Association Idaho State Dental Association Illinois State Dental Society Nevada Dental Association New Jersey Dental Association Oregon Dental Association Washington State Dental Association Also in: Arizona, Minnesota, Montana, North Dakota, Pennsylvania and Tennessee
TDIC reports information from sources considered reliable but cannot guarantee its accuracy.
Need one-on-one risk management guidance? • Get answers to your critical questions through a confidential phone consultation with an experienced TDIC risk management analyst. • Request a consultation at a time that’s convenient for you at tdicinsurance.com/RMconsult or by calling 800.733.0633. • For Risk Management guidance in Idaho, Oregon or Washington, call 800.452.0504.
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