Bloodborne Pathogen Exposure Control Protocol and Post Exposure Protocol
Chemical Hygiene Plan & MSDS
Dental Asepsis and PPE Selection
Laboratory Drain Log Sinks Documentation and Location
Engineering Controls and Work Practices
Hand Washing Sink
Handling Contaminated Waste
Laboratory Safety Procedures
Radiation Safety and Infection Control
Routine Environmental Cleaning
Refrigerator Temperature Monitoring
Standard Operating Procedures
ECU School of Dental Medicine Infection Control Orientation and Annual Training Checklist Name____________________ Title_________________ Date ____________
__ Initial Orientation __ Annual Training
Supervisor _________________ Title _________________ Date ____________
I have read the Infection Control Manual, understand and will comply with all items within this manual, including the following topics. I agree to follow the Standard Operating Procedures as they apply to my job responsibilities. I am able to locate all relevant Clinic Manuals (hard copy and online versions). __Autoclave Use and Monitoring
ECU School of Dental Medicine Laboratory (dedicated sink) Drain Log ECU School of Dental Medicine Refrigerator/Freezer Monitoring and Cleaning Log SoDM Clinic Location __________________ Month____________ Year____
Type of Refrigerator
1˚-5˚C ( 34˚-41˚F)
Temperature Adjusted and Result
ECU School of Dental Medicine Waterline Testing Log Clinic _________________________ Month ________ Year _______
Dental Unit Tested
Result must be
≤500 CFU to pass
PASS or FAIL
Repeat Test Result PASS or FAIL
Appendix H Autoclave Use and Monitoring Purpose: Successful sterilization of any item depends not only on proper cleaning but also on proper preparation, packaging, and positioning in the load. These elements are as critical as choosing the correct exposure time and temperature. It is important that each item be prepared in a manner that will facilitate air removal, steam penetration, and steam contact with all surfaces of the device that are intended to be sterilized. In addition, efficient steam removal is necessary for proper drying and the prevention of wet packages at the end of the sterilization cycle
A. Acceptable wrapping materials
Single use peel packages
Specifically designed metal or plastic container
Medical grade steam sterilization wrap following the AAMI double wrap method
Only sterilization indicator tape should be used to secure packages.
Denote that the package has been exposed to physical conditions (i.e. steam and temperature) present in the steam sterilizer.
It should be placed on the outside of packaging material. This may be used as a form of closure for the package, such as indicator tape. Peel packs are pre-printed with the chemical indicator.
External indicator does not guarantee sterility.
Internal Chemical Indicators
An internal indicator must be used in each package to be sterilized.
The internal indicator should be placed in that area of the package considered least accessible to steam penetration; this may or may not be the center of the pack.
Internal indicator shows that steam and heat penetrated the package interior, but does not guarantee sterility.
Only Biological spore indicators, consisting of spores of Bacillus stearothermophilus that comply with the American National Standard for saturated steam sterilization processes in health care facilities should be used.
Frequency of use:
during initial installation testing
after any major repairs of the sterilizer
at least weekly or with each load if run less than weekly The Biological Indicator shows that the steam and elevated temperature is sufficient to kill spores and verifies the effectiveness of sterilization process.
The package must be labeled with a description of contents, if not visible (example: suture set).
Date of run/cycle
Identification of sterilizer if more than one sterilizer is used
Cycle/run number if used more than once per day
Initials of packer
Use a felt tip indelible ink marker to record on the tape or plastic side of a peel pack. Do not write on wrapper material or paper side of peel packs. This will prevent the ink from running, fading, or bleeding through the package and contaminating the contents.
The following information should be recorded and maintained
Instruments should be carefully inspected for cleanliness and flaws or damage and then dried before packaging.
Instrument sets should be sterilized with all instruments held open and unlocked. Items that can be easily disassembled into component parts should be disassembled prior to sterilization.
Surgical supplies, such as syringes, needles and similar items, must be packaged individually. Syringes should be packaged so that the barrel lies next to the plunger. Stylets should be removed from syringes or trocars.
Tip protectors should be steam-permeable, fit loosely, and be used according to manufacture’s instructions.
Follow manufacture’s recommendations for size, weight, and density of textile packs. Folding textiles in alternating directions will enhance steam penetration, air removal and drying. Packs should not touch chamber walls.
Nested basins should differ in diameter and be processed with absorbent towels or other absorbent material between nested basins of similar size.
Devices with stylets or plugs should be disassembled prior to steam sterilization. Devices with lumens (e.g., catheters, needles, and tubing) should be flushed with distilled, demineralized, or deionized water (as recommended by the manufacturer for use with the sterilizer) immediately before sterilization. If sterilization is delayed more that 24 hours, the devices should be unwrapped, the lumens flushed, and the devices repackaged. Devices with lumens should be placed on the shelf in the chamber so that the lumen is horizontal to the shelf.
Appendix I Forms
ECU School of Dental Medicine Event Report-complete and send confidentially to the Office of Clinical Affairs
ECU Prospective Health Non-Patient Incident Report-complete and send confidentially to the Office of Prospective Health
II. ECU Supervisor’s Report –complete and sends confidentially to the Office of Clinical Affairs
III. North Carolina Industrial Commission Form 19-complete and send confidentially to the Office of Prospective Health
ECU School of Dental Medicine Event Report Rev. Nov 2013 Directions:Administer First Aid (when indicated). Notify Supervisor.
Is this is a possible Blood borne Pathogen Exposure (BBP)?
Vidant employees follow Vidant’s protocol.
Do NOT discharge source patient
Injured Person Calls ECU Office of Prospective Health for
Mandatory Risk Assessment
252-744-2070 (M-Fri 8-4:30 PM) Office closes at 4:30 PM
Do NOT place this form in the patient’s record
Submit this form to Office of Clinical Affairs within 24-hours of event. Attach a 2nd page if needed Phone: 252 737-7008 or Fax 252 737-7198 Reported by _________________________________ Title ______________________ Phone __________________
Date of Event ____/____/____ Time _____ Location (be specific) ________________________________
Dental Provider Name(Do not enter name if provider is the injured party) ___________________________________
Dental Provider Status (Check one) ☐Faculty ☐Resident ☐Student
Supervising Clinical Faculty Name ___________________Phone __________________
Staff Supervisor ___________________________________ Phone __________________
Witness(es) _______________________________________ Phone __________________
Injured Patient*Name ______________________ axiUm number ________ Date of Birth ___/___/___
*If injured party is NOT a patient, only check injured party’s status ☐Faculty ☐Resident ☐Student ☐Staff ☐Visitor Family member notified: ☐yes ☐noFamily MemberName &Phone # ____________________________________
Nature of Injury & how it happenedbe specific:
(E.g., 1-inch laceration right index finger while placing a contaminated 23-gauge needle in sharps container)