Adams School of Dentistry: Infection Control Manual - Chapter 02: Program Administration & Methods of Implementation

Policies, protocols, and guidelines in the Infection Control Manual are developed, implemented, monitored, and evaluated on an on-going basis by the Infection Control Committee and Director of Clinical Compliance. Ultimately, the Infection Control Committee has the authority and responsibility to revise infection control policies and procedures, with consultation from the Associate / Assistant Dean of Clinical Education.

Standard Precautions

Dental procedures are performed in a septic environment that poses significant hazards to dental personnel and patients. Over the past several decades, these hazard have gradually become more complex and contribute to the use of equipment that produces aerosols of saliva, blood, and biofilm. Patient volume seen by Dental professional has also increased, as has the number of patients carrying life-threatening communicable diseases (hepatitis, AIDS, tuberculosis, etc.). Aseptic techniques and procedures are vital disciplines that must be learned, practiced, and performed for every patient encounter. Patients often do not know that they carry life-threatening diseases, which is the basis for standard precautions (formerly Universal Precautions) and each patient must be treated as if they have a communicable disease. Specific information and examples are available through the CDC.

Evaluation Process

Infection control policies and procedures are evaluated through regular peer inspections, infection control violations reported to the Director of Clinical Compliance, and review of current literature published by the CDC, Organization for Safety Asepsis and Prevention (OSAP), EPA, FDA, and the NC State and Federal Health and Human Services. Reporting of violations to the Director of Clinical Compliance can be completed through the Infection Control Violation or Suggestion form or by sending an email to ASOD_ClinicalCompliance@unc.edu. Outside of these areas, infection control inspections performed by peers in predoctoral, graduate, and dental faculty clinics are completed through a standardized checklist.

Violations & Breaches of Infection Control

All incidents are tracked, recorded, and analyzed for quality improvement. Depending on the situation and/or type of incident, an investigation may be necessary. Any student related incident investigations requires that a temporary committee be created and chaired by the Director of Clinical Compliance, with additional members including at least 1 faculty or adjunct and 1 ASOD student. Non-student related incidents will also result in a temporary committee to be created and chaired by the Director of Clinical Compliance, with at least 1 representative of the staff forum or appointee.

After establishing committee representation, the committee will review the circumstances to determine the items listed below, which is modeled per CDC Guidelines. All findings will be documented and attached to the original Incident Report submitted, or a new incident form will be created if one does not already exist.

  1. Identification of incident type and supplemental information:
    • Identify the nature of the breach, type of procedure, and biologic substances involved
    • Review of the work area where the incident occurred
    • Identify what work practices were followed
    • Description of the device or devices in use during the incident, including brand and type
    • Protective equipment that was used at the time of the incident
    • Location of the incident
    • Procedure being performed when the incident occurred
    • Review prior employee, resident, or student training
    • Speak with the individual(s) reporting the violation, if known
    • Discussion with the individual(s) who committed the infraction
    • Review the recommended reprocessing methods or aseptic technique
    • Determine if individual(s) who committed infraction have documented, prior offense. If so, include the number of prior offenses.
  2. Gather additional patient related data:
    • Determine the time frame of the breach and number of patients who were exposed
    • Identify exposed patients with evidence of HBV, HCV, or HIV infections through medical records and/or public health surveillance data
    • Conduct literature review and consult experts
  3. Assess the breach in a qualitative manner
    • Category A: gross error or demonstrated high-risk practice
      • Intentional (Level I – failure to use appropriate safeguards)
      • Unintentional (Level II – intentional conduct that causes, or is likely to cause, bodily harm to self or others)
    • Category B: breach of infection control practice with low to moderate risk of blood exposure event
      • Intentional (Level I – failure to use appropriate safeguards)
      • Unintentional (Level II – intentional conduct that causes, or is likely to cause, bodily harm to self or others)
  4. Decision regarding appropriate notifications
    • Provide corrective action
    • If applicable, apply appropriate enforcement consequences
    • Institute corrective action for division, department, or school

Enforcement

All ASOD personnel who fail to comply with infection control standards, as defined in the Infection Control Manual, will be subject to disciplinary action. Information that has been accumulated through the process outlined in “Violations & Breaches of Infection Control,” will be shared with the Executive Dean, Infection Control Committee, reporting individual(s) (if known), and individual(s) who failed to comply with infection control standards. Report may also include remediation and define the consequences of non-compliance. Based on the results of the investigation, the following actions will be taken:

Level II - Unintentional
Offense # Students Faculty Staff
1st Verbal or written counseling and/or remedial activities Remedial activity and included in performance review Verbal warning and remedial activities effective immediately upon staff notification
2nd Professionalism letter and marked “Below Expectations” for Safety & Infection Control for the clinical day, on the Assessment of Clinical Encounter. Meeting with the chair of the department and a notation added to faculty file Written warning
3rd Clinic suspension for three (3) days and a consultation with the Chief Dental Officer Indefinite clinic suspension until further disciplinary action is assessed, with consultation from HR, up to and including possible dismissal Indefinite clinic suspension until further disciplinary action is assessed, with consultation from HR, up to and including possible dismissal
4th Indefinite clinic suspension and may result in dismissal from program, pending the outcome of Academic Performance Committee review.    
Level I - Intentional
Students Faculty Staff
Indefinite clinic suspension and immediate referral to the Academic Performance Committee Indefinite clinic suspension until further disciplinary action is assessed, with consultation from HR, up to and including possible dismissal Indefinite clinic suspension until further disciplinary action is assessed, with consultation from HR, up to and including possible dismissal

Back to Chapter 01

Proceed to Chapter 03

Print Article

Details

Article ID: 139918
Created
Sun 6/5/22 3:14 PM
Modified
Wed 9/6/23 3:02 PM
Responsible Unit
School, Department, or other organizational unit issuing this document.
Adams School of Dentistry
Issuing Officer
Name of the document Issuing Officer. This is the individual whose organizational authority covers the policy scope and who is primarily responsible for the policy.
Issuing Officer Title
Title of the person who is primarily responsible for issuing this policy.
Director of Clinical Compliance
Next Review
Date on which the next document review is due.
06/07/2025 12:00 AM
Last Review
Date on which the most recent document review was completed.
09/06/2023 12:00 AM
Last Revised
Date on which the most recent changes to this document were approved.
07/24/2023 1:30 PM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
06/07/2022 12:00 AM
Origination
Date on which the original version of this document was first made official.
05/18/2020 12:10 PM