On 14 March 2014 the European Union (Prevention of Sharps Injuries in the Healthcare Sector) Regulations 2014 (“Regulations”) was signed into law. These Regulations implement EU Council Directive 2010/32/EU as required under European law and supplement the general duty of employers to ensure safety in the workplace set out in the Safety, Health and Welfare at Work Act 2005 and the protection of workers from exposure to biological agents provisions of the Safety, Health and Welfare at Work (Biological Agents) Regulations 2013.

For most dental practices in Ireland, the updated Regulations do not require wholesale changes to procedures as safe systems of work are already in place. Many of the duties set out are similar to those already imposed by the 2005 Act and the Biological Agents Regulations.

The updated Regulations, in effect, supplement and specifically adopt those duties that relate to the prevention of sharps injuries in the healthcare sector. Many of the requirements set out in the Regulations are already imposed on all dental practitioners under the Dental Council’s Code of Practice Relating to Infection Control in Dentistry. As such, most dentists are well aware of the dangers posed by the use of sharps and should already have in place appropriate procedures and policies relating to their use.

Dental Protection welcomes the recognition that needlestick injuries are only one form – and indeed a small proportion – of the sharps injuries that have traditionally been suffered by dental healthcare providers. The use of washer-disinfectors has become more widespread in recent years and this has made an important contribution to minimising the risk of inoculation injuries being suffered by members of the dental team while manually handling contaminated instruments.

Risk management opportunities

The existing opportunities for managing the risks associated with sharps injuries may be seen as common sense by some, and/or a natural part of current compliance.

However, issues flagged up by the new Regulations include:

• Unnecessary use of sharps

  Employers must carry out a sharps risk assessment to identify how a risk of exposure to a sharps injury can be eliminated and/or to identify alternative systems that may eliminate or reduce the risk of exposure to a minimum.

• Safe procedures

  Employers must specify and implement safe procedures for using and disposing of sharps, eliminate the unnecessary use of sharps, provide medical devices with sharps protection mechanisms where appropriate and ban the recapping of needles except where those needles have safety and protection mechanisms and do not pose a risk of injury. Re-capping involves the manual replacing of the protective sheath over the tip and shaft of a needle after use and is a technique well known to have been associated with needlestick injuries in the past. It has particular relevance for dentistry because of the level of exposure, i.e. the number of occasions each day when local anaesthetic injection needles are used. Many systems are available whereby this risk can be reduced or eliminated, even when re-sheathing is considered necessary or desirable.

• Reduce risk – disposal

  Employers must reduce the risk of exposure by placing notices of the procedures for disposal, providing clearly marked and safe containers for disposal as close as possible to the area where sharps are used or found and by implementing safe systems of work to prevent the risk of infection by developing a prevention policy, providing training, conducting health surveillance and providing suitable personal protective equipment to workers.

• Vaccination

  Where a risk of exposure is revealed, employers must offer appropriate vaccines and re-vaccinations free of charge and ensure that workers are informed of the benefits and drawbacks of vaccination and a failure to vaccinate.

• Information

  Where there is a risk of exposure, employers must provide to workers sufficient and appropriate information (especially when inducting new team members) regarding the risk of exposure, precautions to be taken to prevent the risk of exposure and the steps to be taken in the case of incidents and accidents as well as information relating to the existing provisions in the other relevant health and safety legislation.

• Training

  Where there is a risk of exposure to relevant workers, employers must provide those workers with suitable and sufficient training relating to that risk, such as training in the correct use of medical devices with sharps protection mechanisms, the risks associated with exposure to blood and body fluid, preventive measures and safe systems of work, the policies and procedures that are in place, the reporting and response procedures that are in place and the measures to be taken where an incident or accident involving sharps occurs.

• Reporting of incidents

  Where a worker becomes aware of any incident, accident or risk of such involving injury or infection from sharps, the worker must report to the employer or immediate supervisor and provide them with all relevant information relating to the incident or accident as may reasonably be requested.

• Know what to do if a sharps injury occurs

  Employers must put in place policies and procedures to be followed when a sharps injury occurs and implement those policies and procedures on such an occurrence. These should outline the responsibility of employees to make employers aware when a sharps injury has occurred and the procedures to be followed.

• Care for injured worker

  When a sharps injury occurs employers must, while maintaining confidentiality, take immediate steps for the care of the injured worker. This includes the provision of post-exposure prophylaxis, necessary medical tests, appropriate health surveillance and counselling, if appropriate. The employer must investigate and record the cause and circumstances of the incident or accident and, where appropriate, take necessary action to prevent a recurrence.

Compliance

A failure to comply with the Regulations is an offence. Although most primary care dental workplaces will be well aware of the risk that sharps represent and how to manage them – including but not limited to the systems described above – there are some situations where it is helpful to be reminded that particular risks exist and need to be managed appropriately:

1. When a new staff member joins the team (including temporary or agency staff, or dental students on outreach training programmes). Do not presume or accept without question the level of knowledge of a new team member, even one who has previous experience in primary dental care. A careful and thorough induction training should always be carried out by an experienced and knowledgeable staff member, and an assessment made both of the level of knowledge of the incoming person and also their practical ability to manage sharps safely and effectively. A record should be kept that this process took place.
2. When any third party is present in the clinical/treatment area for any reason, such as parents and others accompanying patients. Nobody should ever be placed in harm’s way through exposure to sharps/inoculation injuries, through the failure to inform, train and adequately protect them in the workplace.
3. When using sharps away from the normal workplace for any reason – domiciliary visits would be an obvious example.
4. In situations where employers and practice owners are remote from the point of delivery of dental care. This may happen in larger practices, practice groups with branch practices, and obviously, the larger dental corporates with multiple practices and perhaps a regional management structure. In these settings, with larger numbers of staff working across multiple locations, it is more difficult for employers and practice owners to ensure that these risks are being managed consistently well across the entire organisation. While this may be a greater management challenge, the expectation of the new Regulations is precisely the same.

Appendix

Risk controls

The emphasis in the updated Regulations is the control of risks. It is not always possible to eliminate risks altogether. In such cases one applies a “next best” series of options, in turn, until you are left with options that turn to mitigating risk, i.e. accepting that the risk controls are likely to be imperfect and trying to minimise the consequences, if and when the event materialises. This is sometimes referred to as a hierarchy of risk controls. Take, for example, the risk of a nurse suffering a sharps (inoculation) injury when dismantling a contaminated matrix band in readiness for the cleaning, disinfection and sterilisation process.

When selecting risk controls, systematically consider options from each or all of the above approaches; the controls should be proportional to the risk. Using a variety of risk control techniques maximises their effectiveness.

Residual risk

After considering the hierarchy of risk controls, it is possible to assess the effectiveness of the control environment you have put in place.

Satisfactory = Strong controls exist which are operating properly. It is possible to audit the existence and effectiveness of these controls.

Some weaknesses = Controls are in place but some control weaknesses/inefficiencies remain. Improvements are required.

Weak = Controls do not meet an acceptable standard. Many weaknesses/inefficiencies exist in terms of both system/processes and the people who operate them.

An important aspect of the control environment is training, especially if this helps to develop an awareness of how risk controls can be used in combination to maximise their impact.

Use the table below to evaluate the residual risk that results from different combinations of risk rating and control effectiveness. Use your assessments of likelihood (probability), severity and frequency to choose one of the four risk ratings indicated Low > High, then assess the effectiveness of any controls that exist, and select one of the three categories in the vertical scale. The scale of the residual risk is shown in RED.

Assessment of the overall level of risk

Select one of the levels below