Legal Issues, Quality Assurance, and Infection Control Chapter 40 Copyright © 2009, 2006 by...

Legal Issues, Legal Issues, Quality Assurance, Quality Assurance,

and Infection Controland Infection Control

Chapter 40Chapter 40

Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.


Lesson 40.1Lesson 40.1


Learning Objectives Learning Objectives

Pronounce, define, and spell the Key Terms.Pronounce, define, and spell the Key Terms. Describe the components of informed Describe the components of informed

consent with regard to dental radiographs.consent with regard to dental radiographs. Describe the types of laws affecting the Describe the types of laws affecting the

practice of dental radiography.practice of dental radiography. Describe the Consumer-Patient Radiation Describe the Consumer-Patient Radiation

Health and Safety Act.Health and Safety Act. Identify the individual who “owns” dental Identify the individual who “owns” dental

radiographs.radiographs.


Introduction Introduction

As a dental assistant, it is your responsibility to understand As a dental assistant, it is your responsibility to understand the laws that apply to you when you are exposing dental the laws that apply to you when you are exposing dental radiographs.radiographs.

Both federal and state regulations control the use of dental Both federal and state regulations control the use of dental x-ray equipment.x-ray equipment.

To ensure the highest quality and minimal risk to patients in To ensure the highest quality and minimal risk to patients in radiation exposure, a quality-assurance program is radiation exposure, a quality-assurance program is necessary.necessary.

Dental radiography procedures are not usually considered Dental radiography procedures are not usually considered high-risk for the transmission of diseases. However, high-risk for the transmission of diseases. However, infectious diseases present a significant hazard in the infectious diseases present a significant hazard in the dental office and dental professionals are at an increased dental office and dental professionals are at an increased risk of such diseases. risk of such diseases.


Legal IssuesLegal Issues

There are three major categories of legal There are three major categories of legal considerations with which the dental assistant considerations with which the dental assistant should be familiar in regard to the use of x-should be familiar in regard to the use of x-rays in dentistry:rays in dentistry: Federal and state regulations regarding Federal and state regulations regarding

x-ray equipment and its usex-ray equipment and its use Licensure for individuals exposing radiographsLicensure for individuals exposing radiographs Risk management for avoiding potential lawsuitsRisk management for avoiding potential lawsuits


Federal and State Regulations Federal and State Regulations

The use of dental x-ray equipment is regulated by both The use of dental x-ray equipment is regulated by both federal and state regulations. federal and state regulations.

All dental x-ray machines manufactured or All dental x-ray machines manufactured or sold in the United States after 1974 must meet federal sold in the United States after 1974 must meet federal regulations which include safety specifications for regulations which include safety specifications for minimum filtration and accuracy of the milliamperage minimum filtration and accuracy of the milliamperage time and kilovoltage settings.time and kilovoltage settings.

Many states require x-ray machines to be registered Many states require x-ray machines to be registered and charge a fee for this registration.and charge a fee for this registration.

Most states have laws that require inspections of Most states have laws that require inspections of dental x-ray equipment on a regular basis, for instance, dental x-ray equipment on a regular basis, for instance, every 5 years. every 5 years.


Licensure Requirements Licensure Requirements

The Consumer-Patient Radiation Health and Safety Act is The Consumer-Patient Radiation Health and Safety Act is a federal law that requires persons who take dental a federal law that requires persons who take dental radiographs to be properly trained and certified.radiographs to be properly trained and certified.

It is up to the individual state to determine its own policy It is up to the individual state to determine its own policy regarding the qualifications of individuals exposing regarding the qualifications of individuals exposing radiographs.radiographs.

X-ray certification requirements for the dental assistant X-ray certification requirements for the dental assistant vary from state to state. vary from state to state.

Some states require certification by the Dental Assisting Some states require certification by the Dental Assisting National Board; other states may require an additional National Board; other states may require an additional examination.examination.

Each state deals with dental radiography differently. Each state deals with dental radiography differently.


Risk Management Risk Management

Risk-management policies are designed to reduce the Risk-management policies are designed to reduce the likelihood of a malpractice lawsuit against the dentist.likelihood of a malpractice lawsuit against the dentist.

The dental assistant has an important role in risk The dental assistant has an important role in risk management. management.

The dental assistant must be careful never to say anything The dental assistant must be careful never to say anything negative about the x-ray equipment or how it is working. negative about the x-ray equipment or how it is working.

Statements made without thinking—such as “The timer Statements made without thinking—such as “The timer must be off,” “This thing never works right,” or “The must be off,” “This thing never works right,” or “The solutions are weak”—are unnecessary and can make the solutions are weak”—are unnecessary and can make the patient feel uncomfortable. patient feel uncomfortable.

Statements made by anyone at the time of an alleged Statements made by anyone at the time of an alleged negligent act are admissible as evidence in court.negligent act are admissible as evidence in court.


Informed ConsentInformed Consent

It is the dentist’s responsibility to discuss the It is the dentist’s responsibility to discuss the need for radiographs and treatment need for radiographs and treatment procedures with the patient. procedures with the patient.

The dental assistant may participate in the The dental assistant may participate in the process of obtaining informed consent. process of obtaining informed consent.

Patients must give informed consent for Patients must give informed consent for dental radiographs, as well as for other dental radiographs, as well as for other procedures. procedures.


For Valid Informed ConsentFor Valid Informed Consent

The patient must be provided with the The patient must be provided with the following information in lay terms: following information in lay terms: The risks and benefits of the radiographs The risks and benefits of the radiographs The person who will be exposing the radiographs The person who will be exposing the radiographs The number and type of radiographs The number and type of radiographs The consequences of not having the radiographs The consequences of not having the radiographs Any alternative diagnostic aids that may provide Any alternative diagnostic aids that may provide

the same information as the radiographs the same information as the radiographs


LiabilityLiability

Under state laws, the supervising dentist is Under state laws, the supervising dentist is legally responsible, or liable, for the actions of legally responsible, or liable, for the actions of the dental auxiliary. the dental auxiliary.

This is called respondeat superior doctrine. This is called respondeat superior doctrine. It means that the employer is responsible It means that the employer is responsible for the actions of the employee.for the actions of the employee.

However, even though dental assistants work However, even though dental assistants work under the supervision of a licensed dentist, under the supervision of a licensed dentist, they can also be held legally liable for their they can also be held legally liable for their own actions.own actions.


Patient RecordsPatient Records

It is very important to document the exposure It is very important to document the exposure of dental radiographs.of dental radiographs.

The number of films exposed, as well as the The number of films exposed, as well as the quality of the radiographs, may be an quality of the radiographs, may be an important issue in a malpractice suit. important issue in a malpractice suit.

Radiographs that are of poor quality and are Radiographs that are of poor quality and are nondiagnostic reflect poorly on the dentist.nondiagnostic reflect poorly on the dentist.


Documentation of Dental Documentation of Dental Radiographs Radiographs

The dental record must include the following The dental record must include the following information: information: Informed consent Informed consent The number and type of radiographs exposed The number and type of radiographs exposed The rationale for exposing the radiographs The rationale for exposing the radiographs The diagnostic interpretation The diagnostic interpretation


Ownership of Dental Radiographs Ownership of Dental Radiographs

Radiographs are the property of the dentist, even Radiographs are the property of the dentist, even though the patient, or the patient’s insurance though the patient, or the patient’s insurance company, paid for them. company, paid for them.

This is because dental radiographs are a part This is because dental radiographs are a part of the patient’s records. of the patient’s records.

Patients have a right to reasonable access Patients have a right to reasonable access to their records. to their records.

Make an entry in the chart stating when and to Make an entry in the chart stating when and to whom duplicate radiographs were sent.whom duplicate radiographs were sent.

Never give or send the original radiographs Never give or send the original radiographs to a patient. to a patient.


When Patients Refuse Dental When Patients Refuse Dental Radiographs Radiographs

When this occurs, the dentist must decide whether an When this occurs, the dentist must decide whether an accurate diagnosis can be made without radiographs and accurate diagnosis can be made without radiographs and whether treatment can be provided. whether treatment can be provided.

The use of dental radiographs is now the accepted The use of dental radiographs is now the accepted standard of care.standard of care.

No document can be signed to release the dentist from No document can be signed to release the dentist from liability. Even if the patient suggests signing a release or liability. Even if the patient suggests signing a release or waiver that will release the dentist from liability, it would be waiver that will release the dentist from liability, it would be considered invalid if an injury did result.considered invalid if an injury did result.

It should be recorded in the patient’s record if a patient It should be recorded in the patient’s record if a patient refuses recommended radiographs. The dentist must then refuses recommended radiographs. The dentist must then choose whether or not to continue treating this patient.choose whether or not to continue treating this patient.


Patient EducationPatient Education

As a dental assistant, you should understand and be As a dental assistant, you should understand and be sensitive to the patient’s concern and fears about sensitive to the patient’s concern and fears about exposure to radiation during dental radiographs.exposure to radiation during dental radiographs.

The dental assistant is often the person to whom the The dental assistant is often the person to whom the patient feels most comfortable confiding these fears.patient feels most comfortable confiding these fears.

The dental assistant can explain to the patient just The dental assistant can explain to the patient just how important radiographs are in detecting diseases how important radiographs are in detecting diseases and planning treatment.and planning treatment.

Patients can be informed of the federal and state Patients can be informed of the federal and state laws enacted for their protection.laws enacted for their protection.






Name the eight annual tests recommended Name the eight annual tests recommended for x-ray equipment.for x-ray equipment.

Describe the components of a quality-Describe the components of a quality-assurance program.assurance program.

Describe the quality-control tests for Describe the quality-control tests for processing solutions.processing solutions.

Explain the use of a stepwedge.Explain the use of a stepwedge. Discuss the purpose of a reference Discuss the purpose of a reference

radiograph.radiograph.


Quality Assurance in the Dental Quality Assurance in the Dental OfficeOffice

Quality assurance is a means of ensuring that Quality assurance is a means of ensuring that everything possible is being done to produce everything possible is being done to produce high-quality diagnostic radiographs.high-quality diagnostic radiographs.

It includes both quality-control tests to It includes both quality-control tests to monitor the condition of dental x-ray monitor the condition of dental x-ray equipment, view boxes, supplies, and film equipment, view boxes, supplies, and film processing and quality-administration processing and quality-administration procedures, including records of maintenance procedures, including records of maintenance and other logs.and other logs.


Fig. 40-2 Viewbox with clean Plexiglas and new bulb.Fig. 40-2 Viewbox with clean Plexiglas and new bulb.


Fig. 40-3 A, Unexposed film with coin on it.Fig. 40-3 A, Unexposed film with coin on it.


Fig. 40-3 B, Radiograph showing outline of coin.Fig. 40-3 B, Radiograph showing outline of coin.


Fig. 40-4 Radiograph of a stepwedge.Fig. 40-4 Radiograph of a stepwedge.






Explain the infection-control requirements for Explain the infection-control requirements for preparation of a radiography operatory.preparation of a radiography operatory.

Implement the Centers for Disease Control Implement the Centers for Disease Control and Prevention guidelines for infection control and Prevention guidelines for infection control in dental radiology.in dental radiology.


Infection Control in Dental Infection Control in Dental RadiographyRadiography

Dental radiography presents unique infection-Dental radiography presents unique infection-control problems because of the potential for control problems because of the potential for operator contamination and cross- operator contamination and cross- contamination of other patients and other contamination of other patients and other members of the dental team.members of the dental team.

Constant movement by the operator from the Constant movement by the operator from the oral cavity to the exposure controls outside oral cavity to the exposure controls outside the operatory to the darkroom and finally to the operatory to the darkroom and finally to film mounting increases the risk that others film mounting increases the risk that others will be exposed to infectious diseases. will be exposed to infectious diseases.


Surfaces Likely to Become Surfaces Likely to Become Contaminated During Dental X-Ray Contaminated During Dental X-Ray

ProceduresProcedures X-ray tubeheadX-ray tubehead Position-indicating Position-indicating

device (PID)device (PID) X-ray control panelX-ray control panel Exposure buttonExposure button Lead apronLead apron

Dental-chair controlsDental-chair controls Operatory counter surfacesOperatory counter surfaces Darkroom equipmentDarkroom equipment Sleeves on automatic Sleeves on automatic

processorsprocessors


Radiography Operatory Preparation Radiography Operatory Preparation

The first step in the preparation of the operatory The first step in the preparation of the operatory is to determine which surfaces need to be is to determine which surfaces need to be covered or disinfected with a high-level surface covered or disinfected with a high-level surface disinfectant.disinfectant.

In general, surfaces that cannot be easily cleaned In general, surfaces that cannot be easily cleaned and disinfected should be protected with a and disinfected should be protected with a barrier, most commonly plastic or foil. barrier, most commonly plastic or foil.

Surface barriers are preferred for electrical Surface barriers are preferred for electrical switches because of the possibility that the switches because of the possibility that the cleaner or disinfectant will cause an electrical cleaner or disinfectant will cause an electrical short. short.


Fig. 40-6 Radiography operatory with barriers in place.Fig. 40-6 Radiography operatory with barriers in place.


The X-Ray Machine The X-Ray Machine

The tubehead, PID, control panel, and The tubehead, PID, control panel, and exposure button must all be covered or exposure button must all be covered or carefully disinfected. carefully disinfected.


The Lead ApronThe Lead Apron

The lead apron should be considered The lead apron should be considered contaminated and wiped down with a contaminated and wiped down with a disinfectant after each use. disinfectant after each use.


The Dental ChairThe Dental Chair

The back and arms of the chair, the headrest, The back and arms of the chair, the headrest, and the headrest-adjustment controls must all and the headrest-adjustment controls must all be covered or disinfected. be covered or disinfected.

Once the radiography operatory is set up, the Once the radiography operatory is set up, the film and film-holding devices should film and film-holding devices should be prepared. be prepared.


The Work AreaThe Work Area

The work area where the x-ray film and film-The work area where the x-ray film and film-holding devices are placed during exposure holding devices are placed during exposure should be disinfected, after which a barrier should be disinfected, after which a barrier should be placed. should be placed.

This barrier may be a paper sheet, paper This barrier may be a paper sheet, paper towels, or plastic cover.towels, or plastic cover.

Once the procedure has been completed, the Once the procedure has been completed, the barriers should be discarded. Surfaces that barriers should be discarded. Surfaces that are not protected with barriers should be are not protected with barriers should be cleaned and disinfected. cleaned and disinfected.


Fig. 40-7 Fig. 40-7 A, Plastic surface barrier is placed over the work surface. A, Plastic surface barrier is placed over the work surface. B, After each exposure, the dental assistant wipes the film dry using a paper towel B, After each exposure, the dental assistant wipes the film dry using a paper towel and then places the exposed film in a plastic bag that has been taped to the wall. and then places the exposed film in a plastic bag that has been taped to the wall.

(Courtesy of the University of California School of Dentistry, Oral Radiology Department; photographs by Thomas Cao.)(Courtesy of the University of California School of Dentistry, Oral Radiology Department; photographs by Thomas Cao.)

A

B


Preparation of Supplies and Preparation of Supplies and Equipment Equipment

To help decrease the chance of cross-To help decrease the chance of cross-contamination, gather all of the supplies that you contamination, gather all of the supplies that you might need before beginning the procedure. might need before beginning the procedure.

For example, think about the type of film-holding For example, think about the type of film-holding devices, cotton rolls, and bite-wing tabs that may devices, cotton rolls, and bite-wing tabs that may be needed if the patient has an edentulous area.be needed if the patient has an edentulous area.

If you need additional supplies during the If you need additional supplies during the procedure, either use overgloves (food handler’s procedure, either use overgloves (food handler’s gloves) or ask someone for assistance. gloves) or ask someone for assistance.


The FilmThe Film

Dental film should be dispensed from a central area in a Dental film should be dispensed from a central area in a disposable container, such as a paper cup or envelope. disposable container, such as a paper cup or envelope.

A clear plastic barrier envelope may be placed over the A clear plastic barrier envelope may be placed over the film packet to minimize contamination by saliva.film packet to minimize contamination by saliva.

Films enclosed in clear plastic barrier packets are Films enclosed in clear plastic barrier packets are available commercially. available commercially.

The barrier-protected film packets are exposed and The barrier-protected film packets are exposed and brought to the processing area.brought to the processing area.

The barriers are contaminated; the dental assistant must The barriers are contaminated; the dental assistant must remove them very carefully, without touching the inner remove them very carefully, without touching the inner packet, so that he or she can handle the packet with bare packet, so that he or she can handle the packet with bare hands.hands.


Fig. 40-8 Fig. 40-8 Protective barrier on x-ray film.Protective barrier on x-ray film.


Contaminated Film Packets Contaminated Film Packets

The contaminated film packet is the major The contaminated film packet is the major source of cross-contamination during source of cross-contamination during radiographic procedures. radiographic procedures.

When the packet is removed from the When the packet is removed from the patient’s mouth, it is coated with saliva (or, on patient’s mouth, it is coated with saliva (or, on occasion, with blood). occasion, with blood).

For this reason the operator must always For this reason the operator must always wear gloves while handling contaminated film wear gloves while handling contaminated film packets. packets.


Decontamination of Film Packets Decontamination of Film Packets

Wipe saliva from the film packet using a dry Wipe saliva from the film packet using a dry

2 × 2-inch gauze sponge or a paper towel.2 × 2-inch gauze sponge or a paper towel. Do not attempt to sterilize the film packet. Do not attempt to sterilize the film packet.

Heat sterilization will destroy the image. Heat sterilization will destroy the image. Some film manufacturers permit light spraying Some film manufacturers permit light spraying

of film packets with a disinfectant spray; of film packets with a disinfectant spray; however, immersion of the packet in a however, immersion of the packet in a disinfecting solution can allow solution to disinfecting solution can allow solution to seeping into the emulsion, damaging the seeping into the emulsion, damaging the image. image.


Film-Holding Devices Film-Holding Devices

Film-holding instruments and bite-blocks that are Film-holding instruments and bite-blocks that are placed in the patient’s mouth are semicritical items placed in the patient’s mouth are semicritical items and must be sterilized or subjected to high-level and must be sterilized or subjected to high-level disinfection before reuse.disinfection before reuse.

The alternative is to use disposable film holders and The alternative is to use disposable film holders and discard them after a single use. discard them after a single use.

Sterilized film-holding devices should remain Sterilized film-holding devices should remain packaged until the patient is seated and the patient packaged until the patient is seated and the patient can view the opening of the package. can view the opening of the package.

Patients appreciate knowing that proper infection-Patients appreciate knowing that proper infection-control procedures are in place throughout the office. control procedures are in place throughout the office.


Miscellaneous ItemsMiscellaneous Items

Other useful items include cotton rolls that Other useful items include cotton rolls that can be used to stabilize film placement and can be used to stabilize film placement and paper towels that can be used to wipe saliva paper towels that can be used to wipe saliva from exposed films. from exposed films.

A disposable container, such as a paper cup A disposable container, such as a paper cup labeled with the patient’s name, is also labeled with the patient’s name, is also necessary to collect the exposed films. necessary to collect the exposed films.

All miscellaneous items should be dispensed All miscellaneous items should be dispensed from a central supply area. from a central supply area.


Preparation of the OperatorPreparation of the Operator

Gloves and protective clothing must be worn Gloves and protective clothing must be worn by the dental assistant exposing radiographs by the dental assistant exposing radiographs and handling contaminated films. and handling contaminated films.

Because radiographic procedures do not Because radiographic procedures do not involve the aerosol produced by the dental involve the aerosol produced by the dental handpiece, a mask and glasses are optional handpiece, a mask and glasses are optional while radiographic films are being made.while radiographic films are being made.


Fig. 40-9 Fig. 40-9 Wearing the appropriate personal protection, the Wearing the appropriate personal protection, the operator places the lead apron on the patient.operator places the lead apron on the patient.


Infection Control During ExposureInfection Control During Exposure

After gloving, the operator should be careful After gloving, the operator should be careful not to touch any surfaces that have not been not to touch any surfaces that have not been covered.covered.

The best way to do this is to develop a The best way to do this is to develop a sequence in which the operator touches sequence in which the operator touches as few surfaces as possible. as few surfaces as possible.

After each exposed film is removed from the After each exposed film is removed from the patient’s mouth, it must be wiped with a paper patient’s mouth, it must be wiped with a paper towel to remove excess saliva. towel to remove excess saliva.


Collection of Contaminated Films Collection of Contaminated Films

Once dried, each film must be placed in a disposable Once dried, each film must be placed in a disposable container (plastic bag or paper cup) labeled with the container (plastic bag or paper cup) labeled with the patient’s name.patient’s name.

This container will be used to transport the films to the This container will be used to transport the films to the darkroom.darkroom.

The outside surface of this container must The outside surface of this container must not be touched by gloved hands. not be touched by gloved hands.

As a means of preventing film fog caused by radiation, As a means of preventing film fog caused by radiation, the container should never be placed in a room where the container should never be placed in a room where additional films are being exposed. additional films are being exposed.

Exposed films should never be placed in Exposed films should never be placed in the operator’s laboratory or uniform pocket. the operator’s laboratory or uniform pocket.


Film-Holding DevicesFilm-Holding Devices

During exposure, film-holding devices should During exposure, film-holding devices should be transferred from the covered work area to be transferred from the covered work area to the patient’s mouth and then back to the the patient’s mouth and then back to the same area. same area.

Contaminated instruments should never be Contaminated instruments should never be placed on an uncovered surface. placed on an uncovered surface.


Management of Contaminated Management of Contaminated Items After Exposure Items After Exposure

After completion of film exposure, all contaminated items After completion of film exposure, all contaminated items must be discarded and must be discarded and any uncovered surfaces must be disinfected. any uncovered surfaces must be disinfected.

Contaminated radiography items must be handled in the Contaminated radiography items must be handled in the same manner as that recommended for other same manner as that recommended for other contaminated dental instruments.contaminated dental instruments.

The dental assistant must wear gloves to discard The dental assistant must wear gloves to discard contaminated items, including the disposable surface contaminated items, including the disposable surface coverings. coverings.

The operator should carefully unwrap all covered surfaces; The operator should carefully unwrap all covered surfaces; the actual surfaces that are wrapped should not be the actual surfaces that are wrapped should not be touched by gloved hands.touched by gloved hands.

(Cont’d)(Cont’d)


Management of Contaminated Items Management of Contaminated Items After ExposureAfter Exposure

(Cont’d)(Cont’d)

Film-holding devicesFilm-holding devices While the operator is wearing gloves, the contaminated film-holder While the operator is wearing gloves, the contaminated film-holder

must be removed from the treatment area and placed in the area must be removed from the treatment area and placed in the area

designated for contaminated instruments.designated for contaminated instruments. Handwashing Handwashing

After the removal and disposal of all contaminated items, gloves After the removal and disposal of all contaminated items, gloves

must be removed and the hands washed.must be removed and the hands washed. Surface disinfection Surface disinfection

Any uncovered areas that were contaminated during exposure Any uncovered areas that were contaminated during exposure must be cleaned and disinfected with the use of an Environmental must be cleaned and disinfected with the use of an Environmental Protection Agency-registered hospital-grade disinfectant and utility Protection Agency-registered hospital-grade disinfectant and utility

gloves.gloves.


Film Transport Film Transport

The disposable container should never be The disposable container should never be touched by gloved hands.touched by gloved hands.

Only after the gloves have been removed, the Only after the gloves have been removed, the hands have been washed and dried, the hands have been washed and dried, the patient has been dismissed, and the area has patient has been dismissed, and the area has been cleaned and disinfected should the been cleaned and disinfected should the operator carry the disposable container operator carry the disposable container holding the contaminated films to the holding the contaminated films to the darkroom. darkroom.


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