Why so many outbreaks? Myths about safe injections

The Institute of Safe Medication Practices (ISMP) is focusing on unsafe injection practices, and it points out that according to statistics from the Centers for Disease Control and Prevention (CDC), these practices have caused more than 50 outbreaks of bloodborne diseases in the past 10 years.¹ More than 600 patients were infected, according to the CDC.

"These outbreaks represent only a portion of the incidence of bloodborne pathogen transmission caused by unsafe injection practices," according to ISMP.²

There are many misconceptions regarding safe injections practices, reports ISMP, based on its review of previously published research.³

Here are some examples of common misconceptions:

• Reuse of a single-dose vial depends on the size of the vial.

This misconception reflects the wrong believe that a large amount of medication makes it suitable for several patients, ISMP says.

• Changing the needle on a used syringe protects against disease as long as there isn't aspiration of blood and no visible blood in the syringe.

Disease transmission is possible when reusing a syringe even if the needle is changed. A contaminant that isn't large enough to be visible can enter the syringe after injection, especially if the needle and the syringe are still attached.

• Any residential pathogens from the syringe are stopped by bacteriostatic or preservatives in the multi-dose vial.

The preservatives used in multi-dose vials do not destroy all bacteria, and they don't destroy viruses or fungi. "Even if the preservative effectively stopped bacteria from reproducing, there is about a two-hour window during which contaminating organisms remain viable in a multi-dose vial before the preservative fully exerts its effect," ISMP says.²

3. It is safe to use saline solution to flush or dilute drugs for multiple patients as long as they are discarded after 24 hours.

"Limiting use to 24 hours does not prevent the risk of disease transmission," ISMP says.² In fact, using solution that is contaminated for a large number of patients can results in disease being transmitted on a large scale, the agency says. (See the checkitout! column, p. 53, for safe injection practice recommendations. Also, the Association of periOperative Registered Nurses has released recommended practices for medication safety in AORN's 2012 edition of Perioperative Standards and Recommended Practices. To order, go to the website http://alturl.com/xapaa.)

References

Centers for Disease Control and Prevention. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Atlanta: Department of Health and Human Services, CDC; 2007. Web: http://1.usa.gov/GIN5ea.
Institute for Safe Medication Practices. Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed. NurseAdvise — ERR Medication Safety Alert! 2012; 10(1):1-2. Accessed at http://bit.ly/GDKMqk.
Pugliese G, Gosnell C, Bartley JM, et al. Injection practices among clinicians in United States health care settings. Am J Infect Control 2010; 38:789-98. Web: www.premierinc.com/injectionpractices.

Checkitout!

Consider these recommendations to ensure safe injection practices and reduce the risk of disease transmission.

• Use aseptic technique.

Follow standard infection control policies and procedures during preparation and administration of medications to avoid contamination of sterile injection equipment, solutions, and medications. Work with pharmacy to establish policies and procedures for the preparation of any parenteral medications in patient care units.

• Never reuse needles or syringes.

Syringes and needles are both single-use devices. They should not be reused for more than one patient or reused to withdraw additional medication for the same patient.

• Never reuse a syringe after changing the needle.

Both the needle and syringe need to be discarded after a single use. Diseases can still be transmitted if the syringe or pen is reused for a different patient, even after changing the needle.

• Use pen devices as intended.

Insulin pens and other pen devices are intended for single-patient use only! They should be labeled with the patient's name and other identifying information to ensure correct use. The needle should be changed between doses.

• Use fluid infusion and administration sets for one patient.

IV tubing is a single-use, single-patient device that is directly or indirectly exposed to the patient's blood once connected. If a syringe is used to inject medication into an injection port, the tubing and syringe are considered contaminated.

• Never re-enter a vial/bag with a used needle/syringe.

Use a new sterile needle and syringe to re-enter a multi-dose vial even for the same patient.

• Never leave a needle in the septum of a vial.

Leaving a needle or other device inserted into the septum of a vial will allow microbes to enter the vial, contaminating the contents.

• Limit the use of multi-dose vials.

When used, multi-dose vials should be dedicated to a single patient whenever possible. They should be accessed using a new sterile needle and syringe each time. Once a vial cap is removed or the vial is punctured, the manufacturer's expiration date is no longer valid and a revised expiration date (not the date the vial was opened), must be documented on the label. This revised date (also called beyond-use date) should be no longer than 28 days unless the manufacturer specifies otherwise, according to The Joint Commission, the United States Pharmacopeia, and the Association for Professionals in Infection Control and Epidemiology recommendations.

• Use single-dose or single-use vials when possible.

These vials are intended to provide one dose for one patient and should be discarded after initial entry. Never administer medications from a single-dose vial or IV bag to multiple patients or combine leftover contents for later use. If medication is left in the vial, it must be discarded.

• Use prefilled or pharmacy-prepared single-dose syringes when possible.

Prefilled syringes are intended for single-use only. These devices should not be manipulated to withdraw medication for use in multiple patients.

• Never use bags/bottles of IV solutions as a communal supply.

IV bags/bottles of solution are intended for one patient and should not be used as a source of flushes, diluents, or medication preparation for multiple patients.

• Employ a mask for neuraxial injections.

Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space.

• Educate staff and patients.

The One & Only Campaign — ONE needle, ONE syringe, ONLY ONE time — led by the Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition offers free posters, brochures, and videos for healthcare providers and patients. Visit www.oneandonlycampaign.org for these and other resources regarding safe injection practices.

Report medication errors or near misses to the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E) or online at www.ismp.org.

Source: Used with permission from the Institute for Safe Medication Practices. Nurse Advise-ERR 2012; 10(1):2. Accessed at http://www.ismp.org/newsletters/nursing/issues/NurseAdviseERR201201.pdf.