Standards › Standard 31 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DEN-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.10
At a glance
- Amalgam waste is collected in a closed, labelled container.
- Amalgam waste is never flushed to a drain.
- A separator or equivalent collection is in use and serviced on schedule.
- Disposal is by a licensed contractor and recorded (WST-SOP-001).
- Stop and get help straight away if: amalgam waste is flushed to a drain.
1. Purpose
To stop mercury from amalgam waste entering water and the environment (31.10).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Dental amalgam contains mercury. Waste from it, if thrown out or washed down a drain, releases mercury into the environment. Collecting and storing it safely prevents that.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Owns the amalgam waste route and the contractor | Medical director |
| Dental nurse or assistant | Collects and labels the amalgam waste | Clinical director |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Collect.
- Place amalgam waste and extracted fillings in the closed, labelled container.
Key point: Collected.
Step 2. Separate.
- Keep the separator in service and record its service.
Key point: Separated.
Step 3. Dispose.
- Hand the container to the licensed contractor and keep the disposal record.
Key point: Disposed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Separators serviced on schedule | 100% | Quarterly | Clinical director | Escalate to the medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WST-SOP-001 | Waste management | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the CDC guidelines for infection control in dental health-care settings (Kohn et al., 2003), ISO 17665 for moist-heat sterilisation, the Minamata Convention on Mercury (2013), IAEA Specific Safety Guide SSG-46 (2018), Council Directive 2013/59/Euratom, and the ADA guidelines on sedation (2016). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)