TJC alert addresses unsafe injection practices
Patients visiting a clinic for an injection to relieve their pain 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.
Since 2001, at least 49 outbreaks have occurred due to the mishandling of injectable medical products, according to the Centers for Disease Control and Prevention (CDC). In spite of this, adverse events related to unsafe injection practices and lapses in infection control practices are underreported, and it remains a challenge to measure the true frequency of such occurrences.
The Joint Commission (TJC) has released a Sentinel Event Alert, "Preventing infection from the misuse of vials." The alert describes the factors that contribute to the misuse of vials and recommends strategies for improvement.
The misuse of vials primarily involves the reuse of single-dose vials. Single-dose vials typically lack preservatives; therefore, using these vials more than once carries substantial risks for bacterial contamination, growth, and infection. For multiple-dose vials, one survey of healthcare practitioners found that 15% reported using the same syringe to re-enter a vial numerous times for the same patient, and 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.
According to the CDC, adverse events caused by this misuse have occurred in inpatient and outpatient settings. In outpatient settings, a high percentage occurred in pain management clinics. The alert can be found at http://bit.ly/U7gLe2.