Joint Commission issues alert about unsafe injection practices

Patient Safety Monitor Insider

June 18, 2014

An apparent prevalent practice of mishandling injectable vials of medication in healthcare practices had led the Joint Commission to issue a Sentinel Event Alert to bring attention to the problem in both inpatient and outpatient settings, according to a report in Infection Control Today.
The alert comes on the heels of a CDC report estimating that thousands of patients have been infected with Hepatitis or other infections after receiving an injection at their doctor’s office or in the hospital. Since 2001, at least 49 outbreaks have occurred due to the mishandling of injectable medical products, according to CDC statistics cited in the article.
According to the text of the Joint Commission’s Sentinel Event Alert, “thousands of patients have been adversely affected by the misuse of single-dose/single-use and multiple-dose vials. The misuse of these vials has caused harm to individual patients through occurrences and outbreaks of bloodborne pathogens and associated infections, including hepatitis B and C virus, meningitis, and epidural abscesses.”
According to the article, single-dose vials typically lack preservatives, bringing risk for bacterial contamination, growth and infection. For multiple-dose vials, the report cited a survey of health care practitioners that found 15 percent reported using the same syringe to re-enter a vial numerous times for the same patient, and of that 15 percent, 6.5 percent reported saving vials for use on other patients.