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You might think that how you get a tetanus booster or flu shot or how someone gets chemotherapy is settled enough practice that healthcare providers don’t need to be harped on about how to do it right. After all, it’s been more than 30 years since the AIDS crisis began to change the way needles, syringes, and other injection paraphernalia were used. And yet there are still outbreaks of infection due to poor injection practices recorded, alerts issued by organizations like The Joint Commission on safe practices, and multistate efforts to reinforce just what constitutes safe injection practices.
What is it that isn’t happening the right way? What is going wrong?
According to the Centers for Disease Control and Prevention (CDC), since 2001, there have been at least 49 outbreaks of disease due to mishandling of injectable medical products — 19 since 2007. That statistic was mentioned in a sentinel event alert released by The Joint Commission in June, Preventing Infection from the Misuse of Vials (http://www.jointcommission.org/assets/1/6/SEA_52.pdf).
It’s not just one or two bad apples or poorly trained individuals, but a significant enough minority to cause concern: One provider survey1 found that 6% of the nearly 5,500 respondents admitted to sometimes or always using single-dose or single-use vials for multiple patients; 15% said they had used the same syringe to re-enter a multiple-use vial numerous times for the same patient, and of that 15%, 6.5% reported saving vials for another patient. Of the respondents who said they reused a syringe to get an additional dose from a multidose vial and leave it for use on another patient, half were from the hospital setting.
The alert speculates that people are trying to eliminate waste or save money by reusing syringes and making sure all of the medication in even a single-use vial is used, but the potential danger is real. Most of those types of vials don’t contain preservatives, which can increase the risk of bacterial contamination, the alert notes.
In a May 2013 issue of Morbidity and Mortality Weekly Report from the CDC, a grand rounds report on preventing unsafe injection practices,2 the authors note that along with the patients harmed by an outbreak, there can be many other patients who are contacted during the investigations and go through worry and testing before being declared healthy.
"In its simplest form, we are still talking about this due to human error," says Evelyn V. McKnight, AuD, president of Hepatitis Outbreaks National Organization for Reform (HONOReform) in Fremont, NE. "There may be knowledge gaps, with providers being unaware that disease transmission may occur if the needle is changed but not the syringe."
The typical hospital is a very busy place, and providers are stretched thin, coping with time pressures, she says. They may develop shortcuts that are not safe. And while colleagues may see these practices and know they aren’t right, they may be afraid to confront them, or are "in denial that it could happen in their institution or cause harm."
Issues change over time, too. While needles were the big issue 40 years ago, now it’s vials, syringes, IV tubing and other equipment that is intended to be used just once, McKnight says. "We have seen a number of patient notifications because insulin pens were reused on multiple patients," she says. "The insulin pen, which the One and Only Campaign [for injection safety — http://www.oneandonlycampaign.org/] materials make clear, is intended for one patient only. Regrettably, there have been several outbreaks related to drug diversion, in which a hepatitis C positive provider took a loaded fentanyl syringe from the controlled substance area, injected him or herself, refilled the syringe with saline and returned the syringe to the controlled substance area. Currently, HONOReform is active in the national work on drug diversion prevention. It makes sense that we seem to be gathering around prevention of diverted injectables, first."
This isn’t something to sit back on your laurels about, McKnight says. There are plenty of great resources to read up on, make available to your providers, and use as guidelines for QI projects. McKnight recommends the CDC’s injection safety page at http://www.cdc.gov/injectionsafety/, particularly its guideline for isolation precautions for preventing transmission of infectious agents in healthcare settings (Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 [PDF - 3.80 MB]), and the One and Only Campaign.
While it would be ideal to know how many infections these efforts have prevented, McKnight says she’s happy enough to know that people use the materials.
Mary Beth Wenger, a communication specialist with the One and Only Campaign in New York state says even with all the attention, there is obviously still work to do. "We send out a weekly digest of events where there have been transmissions or suspected transmissions of disease due to lapses in safe practices," she says.
Her sense is that there is probably a lack of training. For older nurses who have done things a certain way for decades, learning to use items once that previously were used over and over again can be difficult — there is almost a muscle memory to unlearn. For others, it’s the idea of waste that is untenable, Wegner notes.
In some cases, you may suspect that patient harm came about because of an unsafe injection practice, but you can’t be sure, Wenger notes. "Maybe someone was a drug user and contracted hepatitis that way," she says. That can make it hard to direct remediation programs. If you aren’t sure there is a problem, how do you craft a solution?
Some of the information available from The One and Only Campaign is good for continuing education credits, Wenger notes. There are also posters and other promotional materials available to help spread the word. "Don’t assume everyone is doing the right thing all the time," she says. "Do an in-service on this. Spread the word. In this case, it’s always good to be cautious."
For more information on this topic contact:
• Evelyn V. McKnight, AuD, President, Hepatitis Outbreaks National Organization for Reform, Fremont, NE. Telephone: (402) 708-7951.
• Mary Beth Wenger, Health Communications Specialist, New York State Department of Health, Albany, NY. Email: firstname.lastname@example.org.