Joint Commission Issues Alert on Unsafe Injection Practices

Megan Brooks

June 17, 2014

The Joint Commission wants healthcare organizations to pay more attention to risks associated with improper use of injectable medicines, and to do something about the problem.

"Patients visiting a clinic for an injection to relieve their pain or for chemotherapy don't expect to leave with a new condition such as hepatitis, but unfortunately thousands of patients have been adversely affected in this way when they received an injection at their doctor's office or in the hospital," the commission notes in a statement.

In a Sentinel Event Alert issued June 16, entitled "Preventing Infection from the Misuse of Vials," the commission describes factors that contribute to the misuse of vials and offers strategies to curb the problem.

Since 2001, at least 49 outbreaks have occurred because of the mishandling of injectable medical products, according to the Centers for Disease Control and Prevention (CDC). As a result, more than 150,000 patients had to be notified to be tested for blood-borne pathogens after their potential exposure to unsafe infections. Twenty-one of these outbreaks involved transmission of hepatitis B or C; the other 28 were outbreaks of bacterial infections.

Multiple Use of Single-Use Vials

Lack of adherence to safe infection control practices and aseptic techniques within healthcare organizations is a "significant contributing factor" to the misuse of injectable medicines, the Joint Commission says.

The misuse of vials primarily involves the reuse of single-dose vials, which are intended to be used once for a single patient. "Single-dose vials typically lack preservatives; therefore, using these vials more than once carries substantial risks for bacterial contamination, growth and infection," the Joint Commission says. The CDC's One & Only Campaign emphasizes "one needle, one syringe, only one time."

A survey of 5446 health professionals found that 6% admitted to sometimes or always using single-dose/single-use vials for multiple patients.

For multiple-dose vials, 15% reported using the same syringe to reenter a vial multiple times for the same patient; of that 15%, 6.5% reported saving vials for use on other patients.

"Patients exposed to these types of vial misuse have become infected with the hepatitis B or C viruses, meningitis, and other types of infections," the commission warns.

Adverse events caused by misuse of injectable drugs have occurred in both inpatient and outpatient settings. "In outpatient settings, a high percentage occurred in pain management clinics where injections often are administered into the spine and other sterile spaces using preservative-free medications, and in cancer clinics, which typically provide chemotherapy or other infusion services to patients who may be immunocompromised," the commission notes.

As reported by Medscape Medical News, a recent study found that two thirds of ambulatory surgical centers certified by the Centers for Medicare & Medicaid Services had lapses in basic infection control practices, with 28% of these facilities using medications in single-dose vials for multiple patients.

This may be just the tip of the iceberg. The General Accounting Office warned recently that the extent of unsafe injection practices may be underestimated because of a lack of proper documentation, as reported by Medscape Medical News.

A Culture of Safety

The Joint Commission's Sentinel Event Alert lists recommendations and potential strategies that can be used to help prevent the misuse of injectable medicines and the spread of infection.

The alert calls on organizations to develop and implement effective evidence-based policy and procedures for preventing the misuse of vials; provide annual training and education on injection safety, including how to recognize and report breaches of safe injection and infection control practices with vials; and create a culture of safety, emphasizing that all staff are responsible for reporting risks, errors (including near misses), and adverse events.

"While organizations are required by Joint Commission standards to safely dispense and administer medicines, the accomplishment of these goals depends on preventative action taken by clinical staff who administer injections. Staff should always follow safe injection and infection control practices — including correct aseptic technique, hand hygiene and the one-time-only use of needles and syringes — along with the specific recommendations for single-dose/single-use vials and multiple-dose vials in this alert," the commission advises.

The CDC's comprehensive injection safety resource is available on its Web site.

Sentinel Event Alert. 2014;52. Full text

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