Radiology Lecture 14.docx

Lecture 14 Chapter 15 – Legal Issues and the Dental Radiographer The dental auxiliary must be aware of the legal implications of dental imaging. The dental auxiliary must be knowledgeable about, and comply with, laws that govern the use of ionizing radiation in dentistry. Furthermore, because d...

Lecture 14 Chapter 15 – Legal Issues and the Dental Radiographer The dental auxiliary must be aware of the legal implications of dental imaging. The dental auxiliary must be knowledgeable about, and comply with, laws that govern the use of ionizing radiation in dentistry. Furthermore, because dental imaging has implications for patient care, including the diagnosis of dental disease and treatment planning, the possibility of negligent care exists when dental images are not properly exposed or used. The Consumer-Patient Radiation Health and Safety Act outlines requirements for the safe use of dental x-ray equipment. This federal law also establishes guidelines for the proper maintenance of x-ray equipment and requires persons who perform dental imaging procedures to be properly trained and certified. The process of informing the patient about the particulars of dental imaging is termed disclosure. Informed consent must be obtained from all patients. In the case of a patient who is a minor (generally, those under 18 years of age) or declared to be “legally incompetent,” informed consent must be obtained from a legal guardian. The person disclosing information should use language that the patient can understand easily. Informed consent is defined as consent given by a patient following complete disclosure. Although the governing standards for informed consent may vary from state to state, certain recognized elements of informed consent can be summarized as follows: Purpose of the procedure and who will perform it Potential benefits of receiving the procedure Possible risks involved in having the procedure performed, as well as the possible risks of not having it performed Opportunity for the patient to ask questions and obtain complete information A written consent form including these four elements may be used in obtaining informed consent. If informed consent is not obtained from a patient before the dental imaging procedure, a patient may legally claim malpractice or negligence. The dental professional should not discuss patient treatment with anyone other than the patient, another dentist involved in the patient’s care, and/or a physician who also treats the patient. When a dental auxiliary performs procedures, legal accountability (liability) is presumed to lie with both the supervising dentist and the dental auxiliary. According to state laws, dentists are legally accountable (liable) to supervise the performance of dental auxiliaries. Even though dental auxiliaries work under the supervision of a licensed dentist, auxiliaries are also legally liable for their own actions. The trend in dental negligence or malpractice actions has historically been to sue the supervising dentist alone; however, the dentist and the dental auxiliary may both be sued for the actions of the dental auxiliary. Dental malpractice results when the dental practitioner is negligent in the delivery of dental care. Negligence in dental treatment occurs when the diagnosis made or the dental treatment delivered falls below the standard of care. The standard of care can be defined as the quality of care that is provided by dental practitioners in a similar locality under the same or similar conditions. State laws govern the duration of time within which a patient may bring a malpractice action against the dentist or the auxiliary. This time period is known as the statute of limitations. In many states, this time period begins when the patient discovers (or should have discovered) that an injury has occurred as a result of dental negligence. In such cases, the statute of limitations may not begin until years after the dental negligence occurred. Frequently, it is not until a patient seeks care from another dental professional that he or she becomes aware that previous dental treatment may have been negligent. It is essential that the dental record include the following: Informed consent Number and type of dental images exposed (including retakes) Rationale for these dental images An imaging report including diagnostic information obtained from the interpretation of the images The prescription and the evaluation of images are typically the responsibility of the dentist; therefore, entries in the dental record should be made by the dentist or under the dentist's supervision. Legally, dental images are the property of the dentist, even though the patient or an insurance company may have paid for them. The basis for this ownership of dental images is that images are indispensable to the dentist as part of the patient's record. Patients do have a right to reasonable access to their records. This includes the right to have their complete dental records, including copies of the images, forwarded to another dentist. When transferring to another dentist, a patient can request in writing that his or her dental records be forwarded to that dentist. Duplicates of the images should be created and forwarded and the original dental films retained. Entries made in the dental record should never be erased or blocked out. If an error is made, a clean line should be drawn through the error and initialed by the radiographer, and the correct entry should be added to the record. Dental records and dental images should be retained indefinitely. Because of varying state laws on the statute of limitations, it is not often possible to know when to destroy or discard a patient record. Therefore, patient records should be stored carefully to maintain the integrity of these materials. All dental professionals must be aware of the importance and significance of maintaining patient records in good condition. Some patients may refuse dental imaging procedures. When this occurs, the dentist must carefully consider the situation. The dentist must then decide whether an accurate diagnosis can be made and treatment provided without a dental image. In most cases, patient refusal of dental images compromises the patient's diagnosis and treatment, and the dentist cannot treat the patient. Every effort should be made to educate the patient about the importance and usefulness of dental images. No document can be signed to release the dentist from liability!! Chapter 16 – Infection Prevention and the Dental Radiographer Infectious diseases present a significant hazard in the dental environment, and dental professionals are at an increased risk for acquiring such diseases. Therefore, infection control is a major concern in dentistry. Infectious diseases may be transmitted from a patient to the dental professional, from the dental professional to a patient, and from one patient to another patient. A pathogen is a microorganism capable of causing disease. Dental professionals and dental patients may be exposed to a variety of pathogens that are present in oral or respiratory secretions Cold and flu viruses and bacteria Cytomegalovirus (CMV) Hepatitis B virus (HBV) Hepatitis C virus (HCV) Herpes simplex virus (HSV-1, HSV-2) Human immunodeficiency virus (HIV) Mycobacterium tuberculosis In the dental environment, general routes of disease transmission are: Direct contact with pathogens present in saliva, blood, respiratory secretions, or lesions Indirect contact with contaminated objects or instruments Direct contact with airborne contaminants present in spatter or aerosols of oral and respiratory fluids For an infection to occur, the following three conditions must be present: A susceptible host A pathogen with sufficient infectivity and numbers to cause infection A portal through which the pathogen may enter the host WHAT IS A PATHOGEN? MIRCOORGANISM CAPABLE OF CAUSING DISEASE Antiseptic: A substance that inhibits the growth of bacteria. This term is often used to describe handwashing or wound-cleansing procedures. Asepsis: The absence of pathogens, or disease-causing microorganisms. This term is often used to describe procedures that prevent infection (e.g., aseptic technique, infection control) Bloodborne pathogens: Pathogens present in blood that cause diseases in humans. Disinfect: Use a chemical or physical procedure to inhibit or destroy pathogens. Highly resistant bacterial and mycotic (fungal) spores are not killed during disinfection procedures. Disinfection: The act of disinfecting. Exposure incident: A specific incident that involves contact with blood or other potentially infectious materials and that results from procedures performed by the dental professional. Infectious waste: Waste that consists of blood, blood products, contaminated sharps, or other microbiologic products. Occupational exposure: Contact with blood or other infectious materials that involve the skin, eye, or mucous membranes and that results from procedures performed by the dental professional. Parenteral exposure: Exposure to blood or other infectious materials that results from piercing or puncturing the skin barrier (e.g., a needle-stick injury results in parenteral exposure). Personal protective equipment (PPE): Includes protective attire, gloves, mask, and eyewear. Sharps: Any objects that can penetrate the skin, including, but not limited to, needles and scalpels. Standard precautions: Measures that include a standard of care designed to protect health care personnel and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion. Sterilize: The use of a physical or chemical procedure to destroy all pathogens, including highly resistant bacteria and mycotic spores. Sterilization: The act of sterilizing. PPE Protective clothing must be changed daily or changed more frequently if it is visibly soiled. Gloves must also be worn when touching contaminated items or surfaces. Nonsterile gloves are recommended for examinations and nonsurgical procedures; sterile gloves are recommended for all surgical procedures. Masks and protective eyewear must be used whenever spatter and aerosolized sprays of blood and saliva are likely Chin-length plastic face shields can be used to protect the eyes and face. The mask, when used, must be changed between patients or during treatment if it becomes wet or moist. Hand Hygiene refers to routine hand-washing, antiseptic hand-wash, and antiseptic hand-rub techniques. Instrument Sterilization and Disinfection Critical instruments: Instruments that are used to penetrate soft tissue or bone are considered critical and must be sterilized after each use. Examples include forceps, scalpels, bone chisels, scalers, and surgical burs. In dental imaging, no critical instruments are used. Semi-critical instruments: Instruments that contact but do not penetrate soft tissue or bone are classified as semi-critical. These devices must also be sterilized after each use. If the instrument can be damaged by heat and sterilization is not feasible, high-level disinfection is required. Beam alignment devices (any receptor/film-holding devices) are examples of semi-critical instruments used in dental imaging. Noncritical instruments: Instruments or devices that do not come in contact with mucous membranes are considered noncritical. Because little risk of transmitting infection from noncritical devices exists, intermediate-level or low-level infection techniques are required for their care between patients. Examples in dental imaging include the position- indicating device (PID), the dental x-ray tubehead, the exposure button, the x-ray control panel, the lead apron, and, with digital imaging, the computer keyboard/mouse. Acceptable methods of sterilization include steam under pressure (autoclave), dry heat, and chemical vapor. T/F CRITICAL INSTRUMENTS ARE USED IN DENTAL RADIOGRAPHY. FALSE Cleaning/Disinfection of Dental Unit and Environmental Surfaces EPA-registered chemical germicides labeled as both hospital disinfectants and tuberculocidals are classified as intermediate-level disinfectants and are recommended for all surfaces that have been contaminated. Intermediate-level disinfectants include phenolics, iodophors, and chlorine-containing compounds. Preparation of Treatment Area The dental radiographer can also complete the final infection control procedures that are necessary before exposure. The dental professional must prepare the surfaces that are likely to be touched during the imaging procedure. All these surfaces should be covered with impervious, disposable materials such as plastic wrap, plastic-backed paper, or aluminum foil. This provides adequate protection while eliminating the need for surface cleaning and disinfection between patients. X-Ray Machine - The tubehead, PID, control panel, and exposure button must all be covered or disinfected. Dental Chair - The headrest as well as the headrest adjustment and chair adjustment controls must be covered or disinfected. Work Area - The area where x-ray supplies (e.g., film, sensors) are placed during exposure must be covered or disinfected. Lead Apron - If contaminated, the lead apron must be wiped with a disinfectant between patients. Preparation of Supplies and Equipment Film - Commercially available plastic barrier envelopes that fit over intraoral films can be used to protect the film packets from saliva and minimize contamination after exposure of the film. PSP Sensors - Each sensor must be wrapped in plastic barrier envelopes to protect the sensor from saliva and contamination. Digital Sensors - The sensors used in direct digital imaging (wired or wireless) cannot be heat sterilized. In order to avoid cross-contamination, both barrier techniques and disinfection are required. The supplemental use of a finger cot covering the sensor provides added protection and is often recommended. The CDC recommends cleaning and disinfecting the sensor with an EPA-registered intermediate-level disinfectant after removing the barrier and before using the sensor on another patient. Beam Alignment Devices. Beam alignment devices should be packaged, sterilized in bags, and dispensed from a central supply area. Miscellaneous Items. Disposable items include cotton rolls that can be used to stabilize receptor placement and paper towels that can be used to remove saliva from exposed receptors. PROCEDURE 16-1 SHOULD GLOVES BE WORN TO REMOVE BARRIER ENVELOPES? YES SHOULD GLOVES BE WORN TO REMOVE FILM FROM PACKAGE, IF BARRIER ENVELOPES WERE USED? NO Preparation of the Patient After seating the patient, the dental radiographer must complete the procedures discussed next before completing hand hygiene and putting on gloves. Chair Adjustment - The chair must be positioned so that the patient is seated upright. The height of the chair should be adjusted to a comfortable working height for the dental radiographer. Headrest Adjustment - The headrest must be adjusted to support the patient's head. The patient's head should be positioned with the maxillary arch parallel to the floor. Lead Apron - The lead apron with the thyroid collar must be placed on the patient and secured before any x-ray exposure. Miscellaneous Objects - Miscellaneous objects may interfere with exposure (e.g., eyeglasses, chewing gum, dentures, earrings) and should be removed by the patient at this time. Preparation of the Dental Radiographer Hand hygiene - Hands must be washed with soap or an antiseptic hand-rub product must be used in the presence of the patient. Gloves - Immediately after hand hygiene, gloves must be worn. Mask and Eyewear - Because no aerosolized contaminants are created during imaging exposures, the use of a surgical mask and protective eyewear is optional. Beam Alignment Devices - If beam alignment devices are to be used during exposure, remove the instruments from sterilized packages with gloved hands in the presence of the patient and assemble over a covered work area. Infection Control During Exposure Drying of Exposed Receptors. After each receptor has been placed in the patient's mouth, exposed to radiation, and removed, it must be dried with a paper towel to reduce any excess saliva. Collection of Exposed Receptors. Once dried, each receptor must be placed in a disposable container (paper bag or cup) labeled with the patient's name. This container is used to collect and transport the exposed films to the darkroom or PSP sensors to the scanning area and must not be touched by gloved hands. Exposed receptors should never be placed in the dental radiographer's uniform pocket. Beam Alignment Devices. During exposure, beam alignment devices should be transferred from the covered work area to the patient's mouth and then back to the same area. Infection Control After Exposure Contaminated instruments should never be placed on an uncovered countertop. Contaminated items must be discarded while the dental radiographer is still wearing gloves; this includes disposable materials found on protected surfaces as well. The dental radiographer must carefully unwrap all covered surfaces; the surfaces that are wrapped should not be touched by gloved hands. Ideally, the disposal of all contaminated items should take place in the presence of the patient. Daylight Loader Procedures. Infection control procedures must be followed when using a daylight loader. The first step is to place the paper cup and the gloves in the daylight loader compartment. T/F STERILE GLOVES MUST ALWAYS BE WORN. FALSE T/F MASKS AND SAFETY GLASSES ARE OPTIONAL FOR DENTAL RADIOGRAPHY. TRUE T/F INFECTION CONTROL PROCEDURES DO NOT HAVE TO BE FOLLOWED SINCE NO AEROSOLS ARE PRODUCED IN RADIOGRAPHY. STATEMENT IS FALSE, REASON TRUE T/F COVERED SURFACES MUST ALSO BE DISINFECTED. FALSE WHAT INFECTION CONTROL CATEGORY WOULD GLOVES FALL UNDER? PPE