Joint Commission raises awareness of unsafe injection practices

June 16, 2014

To raise awareness of the prevalence of unsafe injection practices, the Joint Commission has issued a Sentinel Event Alert to educate healthcare organizations and healthcare workers on the risks of misusing vials of injectable medical products.

To raise awareness of the prevalence of unsafe injection practices, the Joint Commission has issued a Sentinel Event Alert to educate healthcare organizations and healthcare workers on the risks of misusing vials of injectable medical products.

According to the Joint Commission, the misuse of vials mainly involves the reuse of single-dose vials, which are meant to be used once for a single patient. Because single-dose vials typically lack preservatives, using these vials more than once carries 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. Exposure to these types of vial misuse can cause infections including hepatitis B or C viruses, meningitis, and others.

“Any healthcare facility utilizing injectable medications needs to ensure absolute compliance with USP 797. This document is intended to minimize the infection risk and subsequent harm to patients. I don’t think it is possible to prevent 100% of infections from injectable medications, as that is an inherent risk, but we should be doing better than we currently are,” said Gina Harper, PharmD, BCPS, clinical coordinator, Poudre Valley Hospital, Fort Collins, Colo.

“Short cuts that ignore 797 and put the patient at risk, in both compounding and administration of medications, need to be eradicated,” Dr Harper said.

Inpatient and outpatient settings have experienced these adverse events caused by this misuse, according to the CDC. 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.