Managing exposure incidents

May 1, 2005
If you or one of your colleagues at work experienced a needle stick or a cut with a contaminated instrument, would you know what to do? Although such injuries are not everyday occurrences in dental practices, following proper post-exposure protocol is critical.

If you or one of your colleagues at work experienced a needle stick or a cut with a contaminated instrument, would you know what to do? Although such injuries are not everyday occurrences in dental practices, following proper post-exposure protocol is critical. OSHA requires reporting and recording such incidents, as well as any medical treatment that may be necessary if the source of the exposure is infectious. Finally, risk-management considerations follow a potentially infectious exposure.

According to the OSHA Bloodborne Pathogens Standard, an exposure incident is:

* A cut or puncture with a contaminated item

* Puncture of the skin with a contaminated needle or instrument

* Splashing of blood and/or saliva onto mucous membranes (eyes, nose, or mouth)

* Splash or spatter of blood and/or saliva onto nonintact (chapped or abraded) skin

OSHA requires that dental employers keep records of these exposures on file. Most OSHA compliance manuals that are available for purchase have forms for recording exposure incidents. The reports should be kept in a confidential employee file. Information typically included in an incident report includes the name of the employee, the date and a description of the incident, and the name of the source patient, if known.

A dental practice is required by OSHA to have a written plan for follow-up and possible treatment of an employee if an exposure incident occurs. This plan must include standard operating procedures (SOPs) for employees to follow. SOPs should include descriptions of first aid appropriate to the type of exposure, to whom the incident should be reported, and who is to complete the incident report. Also included is the physician or medical facility that will provide post-exposure testing, counseling, and appropriate treatment for the employee.

Most OSHA compliance manuals and dental professionals who provide OSHA consulting services can assist a practice in developing post-exposure plans and SOPs. The Centers for Disease Control and Prevention (CDC) also has resources available on its Web site that describe CDC-recommended post-exposure protocol ( Another excellent resource for information on post-exposure plans is the Organization for Safety and Asepsis Procedures (OSAP) (

If an exposure incident happens, the obvious first step is to treat the wound or exposed area. If the skin is exposed to spatter or is punctured, the area should be cleaned with soap and water, and a skin antiseptic such as isopropyl alcohol can be applied. Squeezing the area affected by a cut or puncture is not recommended. If the mucous membranes of the eyes, nose, or mouth are exposed, irrigate or rinse the area thoroughly with water or sterile saline solution.

Once the exposed area has been cleaned, report and record the incident. Recording as soon as possible after an occurrence helps to provide more accurate detail, rather than relying on memory.

The safety manager or the injured employee should then call the designated physician or facility and relate the details of the incident. The physician or medical facility will advise the practice about whether the employee needs to be evaluated, depending on the potential risk of the exposure. If medical evaluation is recommended, the employee should report to the facility immediately to have blood drawn for baseline testing for HIV, hepatitis B, and hepatitis C. If the source patient is known, the employer is required by OSHA to ask the patient to submit for the same tests; however, the patient may decline.

In some cases, the employee may choose not to seek medical treatment after an exposure incident. If this is the case, the employee must sign a statement that he or she has been advised of the risks of exposure to HIV and hepatitis B and C, and that he or she has chosen not to be tested or to receive medical attention.

If the patient is known to be HIV-positive or has AIDS, it is likely that a physician will recommend that the employee take medication for several weeks, known as post-exposure prophylaxis. The drugs are antiretroviral agents that help to fight off an HIV infection. This protocol has been demonstrated to be very successful in preventing HIV infections in health-care professionals who have experienced high-risk exposures to HIV-positive or AIDS patients. More information on post-exposure prophylaxis can be found on the CDC Web site.

Counseling may also be provided to an exposed employee. Counseling includes information about the risks of developing infections as a result of the exposure, signs and symptoms to watch for, precautions to take, and recommendations for additional testing in the future. If the employee has been exposed to HIV, he or she is typically monitored for six months. This is the time frame in which a person will develop HIV after an exposure.

In addition to medically treating and monitoring an employee after an exposure incident, all members of the team should discuss the incident to determine if procedures should be changed to prevent future incidents. Things to consider include how the incident occurred, whether or not the employee was wearing appropriate personal protective equipment (PPE), and whether safety devices were being used, if applicable. If the employee was not wearing PPE, such as safety glasses, it is likely that a spatter injury to the eye could have been prevented. Wearing utility gloves during instrument cleaning would likely prevent a puncture injury from an instrument. And using needle-recapping devices or a one-handed method of needle recapping can prevent needle-stick injuries.

Safety procedures should be thoroughly reviewed after every exposure incident occurs and changes should be implemented where appropriate. One responsibility of the safety manager in a practice is to enforce the OSHA rules on wearing personal protective equipment and the use of safety devices. It is a good idea to review these requirements periodically at team meetings. All the members of the team should remind each other when they observe lapses in safety protocol.

The bottom line is that most exposure incidents result from accidents. Rushing to complete tasks quickly can cause errors in judgment. Some occurrences are simply not preventable, such as when a patient moves during a local anesthetic injection.

However we all have moments when we know that we did something stupid, and are reluctant to admit it. This is a time when pride needs to take a back seat, however. Failing to report an exposure incident can delay necessary medical evaluation and treatment and create potential liability for a dental practice.

Mary Govoni, CDA, RDH, MBA, is the owner of Clinical Dynamics, a consulting company based in Michigan. She is a member of the Organization for Safety and Asepsis Procedures and is a featured speaker on the ADA Seminar Series. She also writes a column for Dental Equipment & Materials magazine. She can be contacted at [email protected].