3 manual for auditors checklist eng bm pos...
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1. INTRODUCTION Clinical Governance is a concept which brings together all the activities that demonstrate to our patients, the community, management and our peers that we hold ourselves responsible for providing safe, high quality health care.
Clinical Governance has been defined as the systems by which the governing body, managers and clinicians share responsibility, and are held accountable, for patient or client care, minimising risks to consumers, and for continuously monitoring and improving the quality of clinical care.
Australian Council on Healthcare Standard1
The effective governance of clinical services involves the participation of all categories of personnel in a range of activities to ensure the quality and safety of clinical services. As Safety of Health Care is one of the dimensions of quality in health provisions, thus, the major aim of any health care should be the safe movement of patients through all parts of the system. Harm arising from care must be avoided and risk minimised in care delivery processes2. The safety of the patients in health care delivery is achieved through:
• Accreditation audits
• Audits – for example on Infection control, Dental Radiation safety, Mercury Hygiene and Safety in Dental Laboratory
• Incident review
• Complaints review. Auditing clinical practice against health and safety standards is a well-established process to identify risk, improve practice and gain assurance. The audit will demonstrate key quality factors and compliance with policy guidelines and procedures. To this end, the Oral Health Division, Ministry of Health Malaysia (MOH) has published various guidelines relating to health and safety in dental practice, namely Guidelines on Infection Control in Dental Practice (1st edition 1996, 2nd edition 2007), Guidelines on Radiation Safety in Dentistry (2006), Position Statement on Use of Dental Amalgam (2002), Manual on Compliance to Dental Mercury Hygiene (1st edition, 2005) and Health and Safety in the Dental Laboratory (2002). The Division has also formulated compliance checklists to be used in inspection audits to track compliance with the guidelines in four areas pertaining to
• Infection control
• Use of dental amalgam and compliance to dental mercury hygiene
• Radiation safety, and
• Safety and health in dental laboratories.
The aim is to use the checklists to audit key factors and procedures that enable identification of areas for improvement in terms of resources, infrastructure, and training needs for health and safety, and to identify ‘good’ practices that may be emulated in dental facilities of the MOH. These checklists are formulated based on the latest literature, with consideration of development and change of technology.
1 The Australian Council on Healthcare Standards (ACHS) - http://www.achs.org.au accessed 8 March 2010 2 Better Quality, Better Health Care: A Safety and Quality Improvement Framework for Victorian Health Services (2005)
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2. OBJECTIVE OF THE COMPENDIUM This compendium aims to assist dental personnel in auditing compliance to health and safety processes contained in the various guidelines produced by the Oral Health Division, MOH. It is intended to clarify the use of checklists to monitor both clinical practices and the environment. This compendium also identifies the role and functions of members of inspection teams at state and district levels. It also aims to ensure that findings from inspection visits are properly recorded in a standardised way, then duly channeled and assessed to enable documentation of good, bad or questionable practices. It should also allow dental practitioners to self-assess their practice against the guidelines. This is one mechanism that will enable the oral health programme to identify areas for improvement in terms of financial support, improvements to infrastructure, procurement of equipment and materials as well as training needs that will enhance health and safety practices in the dental environment. For the time being, inspection visits will cover dental facilities of the MOH, with the intention that the use of the five checklists be later considered for incorporation into the quality system of the oral health programme of the MOH. 3. WHAT THE INSPECTION TEAM NEEDS TO DO (OBSERVE, CHECK & QUESTION) 3.1 The audit checklists are in five separate sections: 1. Management on Safety and Health 2. Infection Control in Dental Practice 3. Use of Dental Amalgam 4. Dental Radiation Safety 5. Health and Safety in Dental Laboratory Auditors are to record what is observed. When certain procedures are not carried out or performed during the visit, questions should be posed to dental personnel, and evidence checked to assess compliance. There are also aspects of the checklists that are not amenable to observation and these calls for questions and checking. However, there are also aspects of the inspection that calls for auditors to quietly observe without comment or question.
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3.2 State Safety and Health Teams There will be 1 state co-ordinator for occupational safety and health in each state, and this person shall be a dental officer appointed by the State Deputy Director of Health (Dental) [TPKN(G)]. Each audit team shall comprise the following personnel:
Dental Nurses
To audit
Management on Safety and Health Infection control Use of dental amalgam *Dental radiation safety
Dental Technologists Safety and health in dental laboratories *Dental radiation safety
Final membership of the audit team(s), however, shall be the prerogative of the TPKN(G), as shall be the number of audit teams to be established in each state. Larger states may need to establish more than one team.
*Not all dental clinics have dental laboratories. In clinics without laboratories, inspection
visits will only involve dental nurses, in which case, inspection for dental radiation safety
shall be undertaken by dental nurses.
3.2.1 Training of Trainers
Training of ‘trainers’ will be conducted in 2010. ‘One team of ‘trainers’ per state shall
undergo training, each team to comprise 3 members – the state co-ordinator, a
dental nurse and a dental technologist. This group shall serve as ‘trainers’ to train
other inspection team members. The TPKN(G) will identify the state co-ordinator and
dental team members to be trained as ‘trainers’ at national level.
The training session shall cover use of the manual and checklists for state co-ordinators, and for members of the team.
3.2.2 Managing and Planning Inspection Visits
Management of implementation of clinical inspections fall under the purview of the TPKN(G) and the state teams.
The TPKN(G) or state co-ordinator will determine the following:
1. The number of inspection teams to be formed in each state
2. The selection of inspection team members
3. The selection of dental facilities for inspection (to aim about 30% of total facilities
per year, inclusive of mobile dental teams)
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4. Arrangements for cross-auditing between states or between districts in each
state.
3.2.3 Terms of Reference of Members of the Team
State Co-ordinators
1. Assist in determining number of teams to be established for the state
2. Assist in appointing inspection team members for the state
3. Oversee selection of dental facilities, data collection and data entry
4. Oversee/undertake data analysis
5. Prepare report/feedback to auditees
6. Compile reports/feedbacks from auditees
7. Oversee undertaking of remedial measures
8. Prepare state report for national level
9. Ensure state reports are sent in November of current year
10. Ensure that health and safety aspects are on the agenda of state meetings
Trainers
1. Undertake echo training on various aspects of inspections for health and safety
- Use of checklists to collect data
- Compilation and data entry
- Data analysis
- Preparation of feedback to auditee
- Preparation of report for state and national level
2. Undertake inspections themselves
3. Render support to other inspection teams.
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3.3 Work Flow
Management of Safety and Health Inspection in Dental Facilities
TPKN(G) - State Deputy Director of Health (Dental) KPP - Principal Assistant Director
NO. ACTIVITY
RESPONSIBILITY
1. Appoint state co-coordinator State Deputy Director of Health (Dental) [TPKN(G)]
2. Appoint safety and health inspection team members
- Dental officers* - Dental Nurses Grade U32 and above (infection control
and use of dental amalgam) - Dental Technologist Grade U32 and above (dental
laboratory and dental radiation)
TPKN(G) / KPP or State Co-ordinator
3. Select dental facilities for annual visits
Inspection Team
4. Schedule the date(s) for inspection(s)
5. Inform the selected clinics
6. Inspect the clinic(s)
7. Collect data
8. Enter data into database
9. Analyse data
Inspection Team / State Co-ordinator
10. Prepare report
11. Give feedback(s) to auditee
12. Compile feedback from auditee and send to state co-ordinator
Personnel-in-charge of dental facility
13. a. If comply, close audit
Inspection Team / State Co-ordinator
b. If does not comply, go back to step 4 and arrange for re-inspection / compliance audit
14. Compile state report for annual state report
15. Send (only soft-copy email) report to the Oral Health Division, MOH
• November of the current year
State Co-ordinator
*option left to TPKN(G)
The role and function of state co-ordinators and inspection team members are shown above.
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4. WHAT THE NATIONAL WORKGROUP NEEDS TO DO
The national level committee will
1. Review the training modules every 5 years based on the latest literature and technology
advances
2. Develop the data entry files to standardize collection of data for analysis and evaluation.
3. Compile an annual national report on all occupational safety and health activities of
inspection teams across the country, to include recommendations for improvements and
remedial measures.
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Oral Health Division Ministry of Health Malaysia
Checklist Safety and Health in Dental Practice
GENERAL INFORMATION State
01=WPKL, 02=Perlis, 03=Kedah, 04=P. Pinang, 05=Perak, 06=Selangor, 07=NS,
08=Melaka, 09=Johor, 10=Pahang, 12=Terengganu, 13=Kelantan, 14=Sabah,
15=Sarawak, 16=WP Labuan
District ……………………....
Category of facility 1= Government, 2 = Private
Name of Clinic ....................……….....................................................................
Date of Inspection
Contact person ......………………………….........................................................
Contact number Tel: ......……....................... Fax :....................................
e-mail ........................................
Type of facility 1. Dental Clinic 2. Non-hospital-based Specialist Dental Clinic 3. Specialist Dental Clinic in Hospital 4. School Clinic/School Dental Center 5. Mobile Dental Clinic 6. Mobile Dental Team 7. Dental Laboratory
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Basic Instructions to Auditors Auditors are to record what is observed. When certain procedures are not carried out or performed during the visit, questions should be asked of dental personnel, and evidence checked for compliance or otherwise. There are aspects of the checklists that are not amenable to observation and call for questions and checking. However, there are also aspects of the inspection in which auditors should quietly observe without comment or question.
1. Tick or write in the relevant columns 2. If not applicable, please indicate ‘NA’ 3. If no handling of such procedures are undertaken, please inquire from the officer-in-charge
(PIC). If the PIC is not available, please pose questions to the next-in-line. Note who you interviewed under ‘comments’.
4. Observe as much as you can. 5. Auditors are advised to make enquiries into the clinic programme prior to the visit. 6. If the facility has more than one workplace, please check all.
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Oral Health Division Ministry of Health Malaysia
Checklist for Management of Safety and Health in Dental Practice
Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist Q/O/C
Tick (����) the relevant Comments Yes No
A. GOVERNANCE
1. Statement on safety and health available (OHSA, sec 16)
Q/C
2. Active Safety and Health Committee (OHSA, 30)
Q/C
3. Mechanism of reporting of accident, danger events, job poisoning and job disease and investigation (OHSA, VIII, Sec 32(i) available ie reporting, investigation, review.
Q/C
4. Programme for maintenance of equipment and facility available (OHSA, Sec 15(2)(a)
Q/C
B. SAFETY ARRANGEMENT
1. Lay out plan and equipment (related to safety) arrangement
Q/C
2. Signage and notice board for information and warning signs
Q/C
3. Electrical source with safety features
e.g. extension wire and socket
C. HEALTH MANAGEMENT
1. Personnel medical surveillance e.g. immunization of personnel
Q/C
Total
General comments, recommendation or area for improvement
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Date : …………
Signature .................................... Signature ………..…………………
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Oral Health Division Ministry of Health Malaysia
Checklist for Infection Control
Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist Q/O/C
Tick (�) the relevant Comments
Yes
No
A. GOVERNANCE
1. Dental officer / person-in-charge aware of infection control guidelines [(MOH/K/GIGI/20.2007(GU)]
Q
2. Written protocol for management of blood (e.g. spill) and other body fluids available
Q/C
B. SAFETY
B.1 HAND HYGIENE
1. Hand washing / alcohol rub done before gloving and between patients after removing gloves
Q/O
B.2 SHARPS MANAGEMENT
1. Needle not re-capped after use Q/O
2. Operator disposes used needle directly into sharps bin Q/O
B.3 WASTE MANAGEMENT
1. Waste from portable spittoon/vaculyser poured into toilet bowl.
Q/O If not, please specify
B.4 PROCESSING INSTRUMENTS
1. Clean and ‘dirty’ areas are clearly separated (e.g. separate rooms/borders identified and marked)
Q/O
2. Use of Type B vacuum autoclave - Instruments packed in pouches
Q/C
3. For chemical sterilisation - instruments completely submerged in solution according to manufacturer’s instructions
Q/O
4. Dental unit water line - Lines flush 1 minute in the morning and 30 seconds between patients
Q/O
C. HEALTH
C.1 FACILITIES
1. Seamless floor and worktop O
C.2 SURGERIES / TREATMENT ROOMS / STERILISATION AREA
1. Hand washing sink / Clinical sink fitted with elbow tap and equipped with liquid soap, disposable hand towels and hand rub(s)
O
2. Sharps container sealed when 2/3 full or up to maximum 1 week
O
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Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist Q/O/C
Tick (�) the relevant Comments
Yes
No
C.3 PERSONAL PROTECTION EQUIPMENT
1. Protective gowns changed once contaminated with blood
Q
2. Single use gloves changed and discarded after each patient
Q/O
TOTAL
General comments, recommendation or area for improvement
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Date : …………
Signature .................................... Signature ………..…………………
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Oral Health Division Ministry of Health Malaysia
Checklist for Use of Dental Amalgam
Guidance: Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist
Q/O/C
Tick (����) the relevant Comments Yes No
A. GOVERNANCE
1. Document Position statement on the use of dental amalgam Q/C
B. FACILITIES
1. Good Ventilation O
2. Air conditioning filter maintained as scheduled Q/C
3. Using Bulk mercury and alloy C
C. WASTE AMALGAM STORAGE
1. Non fragile container C
D. HANDLING
1. All dental staff wearing personnel protective appliances Q/O
2. Instruments free from waste amalgam before sterilizing Q/C
E. DISPOSABLE WASTE AMALGAM
1. Waste Amalgam collected from amalgam trap in the spittoon and separator at suction unit
Q/C
For items 2-4, please choose one of the options below: b. Domestic bin c. Clinical waste bin d. Storage as waste amalgam e. Others (please write in the column comment)
2. Waste Amalgam disposed into ............ C
3. Extracted teeth with amalgam restoration dispose into........ C
4. Contaminated clinical waste with Amalgam including amalgam capsule disposed into.............
C
TOTAL
General comments, recommendation or area for improvement
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Date : …………
Signature .................................... Signature ………..…………………
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Oral Health Division Ministry of Health Malaysia
Checklist for Dental Radiation Safety Number of X-ray machine ………………… Types of X-ray ………………..
Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist Q/O/C
Tick (����) the relevant
Yes No
A. GOVERNANCE
1. Health and safety guidelines
Guideline on Radiation Safety in Dentistry, Ministry of Health, Malaysia 2006
C
2. Warning sign/ light during x-ray operation C
3. Signage for antenatal mother available C
B. SAFETY
1. Dental X-ray Room / Area
1.1 a. Dimension of x-ray area/working area (minimum 2 m X 3 m)
C
b. Lead screen available C
1.2 Method of film processing
a. Instant film C
1.3 Film holder or indicator PID – position indicator device
C
2. Maintenance
2.1 Report/test/QA certificate available C
3. Protective Appliance
3.1 Apron for operator and patient available Q/C/O
C. HEALTH
1. Infection Control
1.1 Availability of equipment and disinfecting agent
Q/C
2. Disposal of waste
2.1 Waste separated according to type (domestic/clinical/chemical)
Q/C/O
3. Health and Risk management
3.1 Monitoring of film reject rate (< 10%) Q/C
TOTAL
General comments, recommendation or area for improvement
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Date : …………
Signature .................................... Signature ………..…………………
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Oral Health Division Ministry of Health Malaysia
Checklist for Safety and Health in Dental Laboratory
Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist Q/O/C
Tick (�) the relevant Comments Yes No
A. GOVERNANCE
1. Guidelines on safety and health in the clinic and dental lab available
Q/C
B. SAFETY
B.1 Facility in dental laboratory
1. Separated area for wet area and dry area O
2. Ventilation adequate O
3. Electric source with safety features
e.g. one plug for one equipment
O
B.2 Engineering control
1. “Certificate of Fitness”/ report/ test/quality assurance certificate available for equipment
C
2. Facility Fume cupboard available O
B.3 Usage and Maintenance Personal Protective Appliance (PPA)
1. DT wearing all PPAs during prosthesis preparation
O
2. Ear-plug available O/Q
B.4 Safety features
1. Gas tank placement i.e. outside the lab. O
2. Machines used for polishing appliance has a vacuum system and safety protector
O
C. HEALTH
C.1 Cross Infection Control
1. Material and equipment for disinfection process available
Q
C.2 Waste Disposal
1. Lab waste segregated according to type Q
C.3 Health and risks management
1. Noise control e.g. hearing test, surveillance Q
Total
General comments, recommendation or area for improvement
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Date : …………
Signature .................................... Signature ………..…………………
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SENARAI SEMAK AUDIT
KESELAMATAN DAN KESIHATAN PEKERJAAN DI FASILITI PERGIGIAN Bahagian Kesihatan Pergigian
Kementerian Kesihatan Malaysia
MAKLUMAT UMUM
Negeri
01=WPKL, 02=Perlis, 03=Kedah, 04=PPinang, 05=Perak,
06=Selangor, 07=NS, 08=Melaka, 09=Johor, 10=Pahang,
12=Terengganu, 13=Kelantan, 14=Sabah, 15=Sarawak,
16=WPLabuan
Daerah IIIIIIII....
Jenis Fasiliti 1= Kerajaan, 2 = Swasta
Nama Klinik ....................III.....................................................................
Tarikh Lawatan
Pegawai untuk dihubungi ......IIIIIIIIII.........................................................
Nombor untuk dihubungi Telefon: ......II....................... Faks ....................................
e-mel ........................................
Jenis fasiliti 8. Klinik Pergigian 9. Non Hospital Based Klinik Pakar Pergigian 10. Klinik Pakar Pergigian di Hospital 11. Klinik / Pusat Pergigian Sekolah 12. Klinik Pergigian Bergerak 13. Pasukan Pergigian Bergerak 14. Makmal Pergigian
Page 17
Bahagian Kesihatan Pergigian Kementerian Kesihatan Malaysia
Senarai Semak Audit Pengurusan Keselamatan Dan Kesihatan Di Fasiliti Pergigian
Q- Soal staf, O- perhati, C –periksa (dokumen dll)
Bil.
Senarai semak Q/O/C
Tanda (√) yang
berkenaan
Catatan
Ya Tidak
A. PENGURUSAN 1. Ada penyataan dasar keselamatan dan kesihatan (OSHA, Seksyen 16) Q/C
2. Jawatankuasa Keselamatan dan Kesihatan Pekerjaan Aktif, JKKP (OHSA, 30)
Q/C
3. Laporan/pemberitahuan mengenai kemalangan, kejadian berbahaya, keracunan pekerjaan dan penyakit pekerjaan dan siasatan [OHSA, Bahagian VIII, Seksyen 32(i)]
4. Terdapat program penyelenggaraan peralatan dan fasiliti [OHSA, Seksyen 15(2)(a)]
Q/C
B. KESELAMATAN
1. Pelan menunjukkan susun atur peralatan (peralatan keselamatan) Q/C
2. Ada signage dan papan tanda makluman dan amaran
3. Sumber elektrik dengan ciri keselamatan Q/C
C. Kesihatan
1. Pengawasan perubatan anggota eg. Ada diuruskan imunisasi personel Q/C
Jumlah
Komen keseluruhan, cadangan dan penambahbaikan
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Tarikh : …………
Tandatangan ................................ Tandatangan ………..…………………
Page 18
Bahagian Kesihatan Pergigian Kementerian Kesihatan Malaysia
Senarai Semak Kawalan Jangkitan Q – soalselidik, O – pemerhatian, C – periksa dokumen/bukti dll
No. Senarai Semak Q/O/C
Tanda (�) yang berkenaan
Ulasan
Ya
Tidak
A. PENGURUSAN
1. Pegawai Pergigian/Pegawai Yang Menjaga tahu tentang Garispanduan Kawalan Jangkitan
Q
2. Ada protokol bertulis tentang pengendalian darah dan bendalir tubuh
Q/C
B. KESELAMATAN
B.1 HIGIN TANGAN
3. Mencuci tangan / alcohol rub dilakukan sebelum memakai sarung tangan. Antara pesakit dan selepas menaanggal gloves
Q/O
B.2 PENGENDALIAN BAHAN TAJAM
1. Tidak menyarung semula penutup jarum suntikan Q/O
2. Operator membuang jarum suntikan terus ke dalam sharps bin
Q/O
B.3 PENGENDALIAN SISA
1. Sisa dari spitton mudah alih/vaculyser dibuang di dalam longkang
Q/O
B.4 PEMPROSES PERALATAN
1. Kerja-kerja pembersihan peralatan ‘kering dan basah’ dilakukan di ruang yang berasingan dan bertanda/bersempadan
Q/O
2. Menggunakan Type B vacuum autoclave –Peralatan dipek dalam pouches
Q/C
3. Bagi pensterilan chemical – peralatan direndam sepenunhnya mengikut arahan pengeluar
Q/O
4. Disinfek Dental unit water line dilakukan- flush 1 minit pagi dan 30 saat antara pesakit
Q/C
C. KESIHATAN
C.1 FASILITI
1. Lantai dan permukaan kerja seamless O
C.2 BILIK SURGERI/BILIK RAWATAN/RUANG PENSTERILAN
1. Sinki Basuh Tangan/klinikal dipasang tap bersiku O
2. Sisa Bahan Tajam ditutup apabila 2/3 penuh atau sehingga tempoh 1 minggu
Q/C
C.3 ALAT PELINDUNGAN DIRI (APD)
Page 19
Q – soalselidik, O – pemerhatian, C – periksa dokumen/bukti dll
No. Senarai Semak Q/O/C
Tanda (�) yang berkenaan
Ulasan
Ya
Tidak
1. Gaun pelindung ditukar jika tercemar dengan darah
Q
2. Sarung tangan ditukar dan dibuang selepas setiap orang pesakit
Q/O
Jumlah
Komen keseluruhan, cadangan dan penambahbaikan
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Tarikh : …………
Tandatangan ................................ Tandatangan ………..…………………
Page 20
Bahagian Kesihatan Pergigian Kementerian Kesihatan Malaysia
Senarai Semak Penggunaan Amalgam Pergigian
Q – soalselidik, O – pemerhatian, C – periksa dokumen/bukti dll
Bil. Perkara Q/O/C
Tanda (�) yang berkenaan
Catatan/Ulasan
Ya Tidak
A. PENGURUSAN
1. Ada dokumen dasar “Position statement on the use of dental amalgam”
Q/C
B. PRASARANA
1. Ventilasi dan pengudaraan baik O
2. Penapis penyaman udara di selenggara secara berjadual
Q/C
3. Bulk mercury and alloy masih diguna C
C. PENYIMPANAN SISA AMALGAM
1. Bekas simpanan sisa amalgam tahan pecah C
D. PENGENDALIAN
1. Semua anggota pergigian memakai alat pelindung diri semasa pengendalian amalgam
Q/O
2. Semua peralatan untuk dibasmi kuman didapati bebas dari sisa amalgam pada hari lawatan
Q/C
E. PEMBUANGAN SISA AMALGAM
1. Sisa amalgam dibuang dari perangkap amalgam (amalgam trap) di spittoon dan unit suction
Q/C
Perkara 2-4, sila pilih yang berikut:
a. di dalam tong domestik C
b. di dalam tong sisa klinikal C
c. disimpan sebagai sisa amalgam C
d. lain-lain (catatkan dalam ruang catatan/ulasan)
C
2. Sisa amalgam dibuang............
3. Gigi yang bertampalan amalgam yang dicabut dibuang............
4. Sisa klinikal yang tercemar dengan amalgam (misalnya gauze, cotton roll, dental napkin) termasuk kapsul amalgam dibuang.............
Komen keseluruhan, cadangan dan penambahbaikan
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ……………………… Auditee ………..………………… Tarikh : …………
Tandatangan ................................ Tandatangan ………..…………………
Page 21
Bahagian Kesihatan Pergigian Kementerian Kesihatan Malaysia
Senarai Semak Keselamatan Sinaran Perubatan Pergigian Bilangan Mesin X-Ray …………… Jenis Mesin X-Ray………………..
Q – soalselidik, O – pemerhatian, C – periksa dokumen/bukti dll
Bil. Perkara Q/O/C
Tanda (�) yang berkenaan
Catatan/Ulasan
Ya Tidak
A. PENGURUSAN
1. Garis panduan keselamatan dan kesihatan pekerjaan berikut di klinik pergigian
Guideline on Radiation Safety in Dentistry, Ministry of Health, Malaysia 2006
C
2. Ada tanda amaran/ lampu amaran x-ray
3. Ada tanda amaran untuk ibu mengandung C
B. KESELAMATAN
1. Kemudahan Ruang X-Ray Pergigian
1.1 a. Dimensi ruang x-ray/ kawasan kerja (minima 2 meter X 3 meter)
C
b. Ada penghadang x-ray (lead screen) C
1.2 Pemprosesan filem, mengguna….
a. Instant film C
1.3 Ada aksesori – pemegang filem (PID – position indicator device)
C
2. Penyelenggaraan
2.1 Ada laporan/ ujian/ sijil jaminan mutu untuk peralatan x-ray pergigian yang digunakan
C
3. Alat Pelindung Diri (APD)
3.1 a. Ada apron untuk pengendali dan pesakit Q/C/O
C. KESIHATAN
1. Kawalan Jangkitan Silang
1.1 Kemudahan bahan dan peralatan disinfektan (proses kawalan jangkitan silang)
Q/C
2. Pembuangan Sisa Bilik X-ray
2.1 Sisa diasingkan mengikut jenis (domestik/ klinikal/ bahan kimia)
Q/C/O
3. Pengurusan Kesihatan dan Risiko
3.1 Ada pemantauan Film Reject Rate (< 10%) Q/C
JUMLAH
Komen keseluruhan, cadangan dan penambahbaikan
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Auditor …………… Auditee ………..………………… Tarikh : …………
Tandatangan ....................... Tandatangan ………..…………………
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Bahagian Kesihatan Pergigian Kementerian Kesihatan Malaysia
Senarai Semak Keselamatan Dan Kesihatan Pekerjaan Di Makmal Pergigian
Q – soalselidik, O – pemerhatian, C – periksa dokumen/bukti dll
Bil. Perkara Q/O/C
Tanda (�) yang berkenaan Catatan
Ya Tidak
A. PENGURUSAN
1. Ada garis panduan keselamatan dan kesihatan pekerjaan di klinik atau makmal pergigian
Q/C
B. KESELAMATAN
B.1 Kemudahan Makmal Pergigian
1. Terdapat ruang berasingan untuk kawasan basah (wet area) dan kering (dry area)
C
2. Ventilasi dan pengudaraan baik Q/C/O
4. Punca kuasa elektrik dengan ciri keselamat an
Q/C/O
B2. Kawalan Kejuruteraan
4.1 Ada “Certificate of Fitness”/ laporan/ ujian/ sijil jaminan mutu untuk peralatan yang digunakan
Q/C
4.2 Terdapat kemudahan fume cupboard
C/O
B3. Penggunaan dan Penyelenggaraan Alat Pelindung Diri (APD)
1. JT memakai APD semasa memproses prostesis
Q/O
2. Ear-plug Q
B4. Ciri-ciri Keselamatan
1. Kedudukan tangki gas di luar makmal
O
2. Kemudahan pelicinan dan penggilapan prostesis/ aplians dilengkapi sistem penyedut debu dengan pelindung keselamatan
O
C. KESIHATAN
C.1 Kawalan Jangkitan Silang
1. Kemudahan bahan dan peralatan disinfektan
Q
C2. Pembuangan Sisa Makmal
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Q – soalselidik, O – pemerhatian, C – periksa dokumen/bukti dll
Bil. Perkara Q/O/C
Tanda (�) yang berkenaan Catatan
Ya Tidak
1. Sisa makmal diasingkan mengikut jenis
Q
C.3. Pengurusan Kesihatan dan Risiko
1. Kawalan kebisingan Q
JUMLAH
Komen keseluruhan, cadangan dan penambahbaikan
………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………
Auditor ………………… Auditee ………..………………… Tarikh : …………
Tandatangan .......................... Tandatangan ………..…………………
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