Perilous Infection Control Practices with Needles, Syringes, and Vials Suggest Stepped-up Monitoring is Needed

ISMP Medication Safety Alert 

In This Article


A recent online survey of 5,446 healthcare practitioners reveals an alarming lapse in basic infection control practices associated with the use of syringes, needles, multiple-dose vials, single-use vials, and flush solutions.[1] Survey respondents primarily included registered nurses (89.5%) who worked in hospitals. While the majority of nurses and other healthcare practitioners appear to follow infection control practices consistent with current recommendations,[2] some survey respondents clearly place patients at risk for transmission of blood-borne diseases, according to information we received from the survey sponsor, Premier Healthcare Alliance, while highlighting publication of the survey by Pugliese et al. in the American Journal of Infection Control ([1]

The survey showed some disturbing results:

  • Nearly 1% of respondents admitted to sometimes or always reusing a syringe for more than one patient after only changing the needle

  • 6% of respondents admitted to sometimes or always using single-dose/single-use vials for multiple patients

  • 15% of respondents reported using the same syringe to re-enter a multiple-dose vial numerous times; of this group, about 7% reported saving these multiple-dose vials for use with other patients

  • 9% of respondents sometimes or always use a common bag or bottle of IV solution as a source of flushes and drug diluents for multiple patients.

Each of these unsafe practices has been associated with disease transmission and is explicitly prohibited by the Centers for Disease Control and Prevention (CDC).[2]

Comments provided by respondents involved in these unsafe practices demonstrated a general lack of awareness regarding safe infection control practices as well as numerous misconceptions. For example, one comment frequently made was that the reuse of a single-dose vial depended on the size of the vial, reflecting a misconception that a large volume of medication alone makes it suitable for multiple patients.

Another misconception is that changing the needle on a used syringe is sufficient protection against disease transmission if aspiration of blood does not occur and there is no visible blood in the syringe. While most respondents called reuse of a syringe "appalling," some respondents appeared unaware that disease transmission was possible when reusing a syringe when the needle was changed. Pathogenic contaminants not visible to the eye can enter the syringe after injection, particularly while the needle is still attached to the syringe. We've published numerous articles about this problem, including an alert in our February 12, 2009, newsletter after a hospital placed 2,114 insulin-dependent diabetic patients at risk for acquiring blood-borne diseases when staff used insulin pen devices for multiple diabetic patients after only changing the pen's needle between patients.

Reuse of a syringe to withdraw a medication or solution from a multiple-dose container may not be overt; rather, this unsafe practice is probably engaged in without much thought when multiple doses of the medication (e.g., lidocaine) or solution (e.g., saline) are required during a single procedure. If syringes are deliberately reused after changing the needle, practitioners may erroneously believe that any residual pathogens will be halted by the bacteriostatic or preservative agents in the multiple-dose vials. While common preservatives used in multiple-dose vials may be bacteriostatic, they will not destroy all bacteria, and they do not have antiviral or antifungal activity. Furthermore, even if the preservative effectively stops bacteria from reproducing, there's about a 2-hour window during which contaminating organisms may remain viable in a multiple-dose vial before the preservative fully exerts its effect.[3]

Comments made by respondents regarding the use of a bag or bottle of IV solution (e.g., saline) as a common source of flushes or drug diluents for multiple patients suggest some awareness regarding the risk of contamination. Nevertheless, other respondents erroneously suggested this practice was safe because they discarded the solution after 24 hours. However, limiting use to 24 hours does not prevent disease transmission if the bag becomes contaminated. Further, use of a contaminated solution for large groups of patients can result in widespread disease transmission.

It's been more than a decade since we first wrote about the risks associated with these practices. In fact, a hepatitis B outbreak related to the reuse of syringes to access multiple-dose heparin vials was the topic of a feature article during the inaugural year of the ISMP Medication Safety Alert! in 1996.[4] Since then, the topic has been covered in dozens of feature articles, Worth Repeating commentaries, and Safety Briefs in our publications. According to the CDC, in the past 10 years there have been more than 50 outbreaks of blood-borne transmission of hepatitis B, hepatitis C, and HIV that required notification of more than 125,000 potentially exposed patients and identification of more than 600 who became infected. The study authors suggest that these outbreaks represent only a portion of the incidence of blood-borne pathogen transmission caused by unsafe injection practices. Many outbreaks and sporadic transmissions of hepatitis B and C, for example, go unrecognized because patients who are infected may be initially asymptomatic or have mild, non-specific symptoms for years.


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