FOCUS ON INFECTION PREVENTION Prevent the Occurrence of Bloodborne Disease Transmission Associated with Unsafe Injection Practices ABSTRACT INTRODUCTION Lapses in basic safe injection practices Outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in patients and infection control expose patients across the nation have been associated with unsafe injection practices. Lapses in basic to needless risk of transmission of infection control expose patients to needless risk of transmission of bloodborne patho- bloodborne pathogens. The Centers for gens.1 The Centers for Disease Control and Prevention (CDC) and U.S. public health Disease Control and Prevention and U.S. officials identified 51 outbreaks of HBV and HCV infection from July 1998 through public health officials identified 51 reports June 2009. More than 75,000 patients were notified of potential exposure and at of outbreaks of hepatitis B virus and least 620 patients became infected or died with HBV or HCV as a result of exposure. hepatitis C virus infection primarily asso- The outbreaks were identified in a variety of healthcare settings, including hospitals, ciated with unsafe injection practices in long-term care facilities, outpatient clinics and ambulatory surgical facilities, and hemo- patients in the United States from 1998 dialysis facilities.2,3 through 2009. Of the 75,000 patients These numbers may represent only a fraction of actual cases. Many outbreaks and who were placed at risk, 620 became sporadic transmissions go unrecognized.4 Identifying epidemiological links to a com- infected or died as a result of exposure. mon healthcare provider or facility is complicated by an incubation period of up to six Events of unsafe syringe reuse reported months, during which a patient may have multiple healthcare encounters,2 and by the to the Pennsylvania Patient Safety high proportion of patients with new HBV or HCV infections who are asymptomatic Authority from 2004 through 2010 were or have mild nonspecific symptoms.4 associated with delivery of injectable medications during surgery, vaccina- Investigations of the healthcare-acquired outbreaks by CDC and state and local health tions, and bedside care. This article departments have resulted in malpractice suits filed by patients, referral of providers describes approaches to integrate safe to licensing boards for disciplinary actions, and the revocation of medical and nursing injection strategies into clinical practice licenses.4 and explains the key components of an Strategies that can be applied to reverse the frequency and magnitude of the transmis- infection prevention program, including sion of bloodborne pathogens caused by unsafe injection practices include (1) dispelling dispelling the misperceptions associated misperceptions surrounding unsafe injection practices, (2) increasing the awareness of with unsafe injection practices, increas- safe injection practices, and (3) oversight of compliance with safe injection practices.1 ing the awareness of safe injection Unsafe injection practices reported to the Pennsylvania Patient Safety Authority practices, and oversight of compliance include the following: with safe injection practices. (Pa Patient Saf Advis 2011 Jun;8[2]:70-6.) IV propofol was injected into the IV tubing of two patients using the same syringe with the rationale that the probability of communicable disease is extremely low due to the IV port location high away from the IV site. No backflow of fluid was visible and the IV was free flowing. During a procedure, a patient received intravenous propofol from a syringe that had been used on the previous patient. Infectious disease [department] was consulted and recommended this patient and source patient be tested for HIV and hepatitis B and C. A staff person who was administering the vaccine accidentally stuck his own thumb. The patient was then administered the vaccine with the same needle. A patient reported that the nurse used the same syringe from another patient’s IV line, drew fluid from his IV bag, and then reused the syringe to flush the other patient’s IV. In a patient being intubated, the physician injected more fentanyl into the pulmonary artery catheter using the same syringe that had not been capped and without cleaning the infusion port. During administration of influenza vaccinations, the injection was given and the needle recapped. A second volunteer picked up the same syringe and vaccinated a second person. Page 70 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority DISPELLING THE reused. Contamination actually extends infect subsequent patients, without visible MISPERCEPTIONS SURROUNDING not just to the needle but also to the evidence of contamination.7 SAFE INJECTION PRACTICES syringe when injections are administered Never use the same syringe used to draw by any route.4 (See Figure.) Prevention of Misperceptions surrounding safe injection blood or infuse meds into an IV port, unsafe syringe reuse includes the follow- practices have been associated with a wide including from the fluid path port that is ing rationale: The variety of procedures, including delivery several feet away from the IV site. of intravenous (IV), intramuscular (IM), Never use the same syringe on more risk for syringe contamination is not and intradermal medications, and flush- than one patient, even if the needle is eliminated by the intervening lengths ing IV lines or catheters. The delivery changed. A syringe may become con- of IV tubing or the presence of heparin of anesthesia was a common factor in taminated because the negative pressure locks or check valves.5,7 Separation from approximately half of the identified out- generated when the needle is removed the patient’s IV by distance, gravity, or breaks. During outbreak investigation, the may cause aspiration into the syringe of a positive infusion pressure does not ensure following breaches by healthcare person- small amount of blood remaining in the that small amounts of blood are not nel were identified in several categories of needle, even if blood is not visible.5 Ster- present.7 well-established fundamental principles of ile injection devices, such as syringes, are The following steps can minimize the infection control:1,2 single-use patient items.6 risk of reuse of contaminated injection — Unsafe syringe reuse Never use the same syringe to inject more equipment:8,9 Contamination of shared medica- than one patient, even if the user only — — Remove packaging immediately tion by reused syringes pushes the syringe plunger and does not before use, and prepare syringes as draw back before injecting. A common close to administration time — Contamination of medical equip- misconception is that the syringe does as possible. ment, supplies, and the environment not become contaminated if the plunger — Activate a sharps safety device as Unsafe Syringe and Overt is only pushed to inject medications and soon as a procedure is completed; not pulled to aspirate or withdraw.1 Even Needle Reuse this isolates the needle so that it when only positive pressure is applied, a The dangerous practice of syringe reuse never poses a hazard. microscopic amount of blood containing may be related to the misperception that viral particles can flow back into the nee- — Discard lancets, syringes, and contamination is limited to the needle dle and syringe in sufficient quantities to needles into a designated sharps device when a syringe and needle are container immediately after use. Figure. Unsafe Injection Practices and Disease Transmission New Same vial vial (now tainted) Clean same syringe New needle needle Clean HCV-infected Clean syringe syringe patient new needle dirty needle MS11185_3 1. Clean needle and 2. When used on an HCV-infected 3. When again used to draw medication, 4. If a contaminated vial is subsequently syringe are used to patient, backflow from the a contaminated syringe contaminates used for other patients, they can draw medication. injection or removal of the needle the medication vial. become infected with HCV. contaminates the syringe. Source: Centers for Disease Control and Prevention. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada 2007. MMWR 2008 May 16 [cited 2011 Feb 28]. Available from Internet: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5719a2.htm. Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 71 ©2011 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION — Use sharps safety devices whenever Never use a common bag of IV solution Contamination of Medical as a source of a flush or medication dilu- possible (e.g., single-use auto dis- Equipment, Supplies, and the ent for more than one patient. Accessing abling lancets, syringes). Environment an IV bag or medication diluent with a syringe that has already been used to flush Investigations of HBV infection outbreaks Contamination of Shared a patient's IV or draw blood from a cen- resulting in several deaths in long-term Medication by Reused Syringes care facilities found lack of adherence to Restricting vials to single patient use pro- tral line increases the number of patients who can be exposed from a single con- standard precautions, such as failure to vides an extra layer of safety to prevent implement long-standing recommenda- patient-to-patient bloodborne pathogen taminant. Bloodborne pathogens can be present in sufficient quantities to produce tions against sharing finger stick devices transmission via contamination of medica- tion vials. Residual content of the vial can infection in the absence of visible blood, and sub-optimal hand hygiene and glove be intentionally or unintentionally used on without clouding or other visible evidence use.10 Outbreaks have occurred from con- additional patients. The reuse of a needle or of contamination.7 tamination of multidose vials and because syringe to withdraw medication from a vial, supplies used to prepare IV medications Never pool leftover contents from mul- IV flush, or medication diluent can transfer for multiple patients were stored in a tiple vials to obtain a sufficient dose. contaminants to the vial or fluid and has contaminated workspace.2 Preventing This practice increases the risk of serial repeatedly been shown to result in transmis- contamination of equipment, supplies, contamination of additional vials.4,6 sion of HBV and HCV4 (see Figure). and the environment includes the follow- Many single-dose vials do not have a The practice of reusing a syringe for addi- ing strategies: bacteriostatic or preservative agent; once tional doses from a medication vial even contaminated, the opportunities for bac- Never use equipment designed for single- for the same patient is considered unsafe terial growth increase relative to elapsed person use (e.g., reusable finger stick as breaches in aseptic technique between time between uses.1 Bacteriostatic agents devices, insulin pens, lancets) on more doses can result in contamination of the than one patient. Microscopic amounts used in multidose vials are not effective vial. This can occur through unrecognized against hepatitis and other viruses. of blood in the cartridge may contain contact between the syringe and the infectious viral particles that can inoculate Never leave a needle, cannula, or spike patient’s skin, syringe or needle contact bloodborne pathogens into a patient’s fin- device inserted into a medication vial with contaminated IV tubing or heparin rubber stopper (even if the stopper has ger stickwound.11 HBV and HBC have been lock, or putting the syringe down on a a one-way valve). Vial contamination shown to remain infectious in the environ- contaminated surface between doses.1 The occurs when environmental microorgan- ment in dried blood for up to a week and rationale for the adoption of practices to isms collect on the spiking device or 16 hours, respectively; either virus may be prevent contamination of shared medica- needle. Sterile solutions are then contami- present in the absence of visible blood in tions includes the following precautions: nated when poured through or withdrawn sufficient quantities to cause infection.12,13 Never access a medication vial with a from the spout or stopper.8 In 2009, the U.S. Food and Drug Adminis- syringe or a needle that has already been tration issued an alert to remind healthcare Strategies to reduce the risk of contami- used to administer medication to another providers and patients that insulin pens are nation of vials or diluents include the patient. Even when the needle is changed designed for single-patient use and should following:1,8 and the vial is swabbed with alcohol, be identified with the name of the patient. reusing a syringe to draw up additional — Purchase single-dose medication and Healthcare facilities should review their medication can contaminate the vial or flush vials whenever possible. If multi- policies and educate their staff regarding bag containing the medication or solution dose vials must be used, dedicate them safe use of insulin pens.14 As with syringes, and expose subsequent patients if the bag to a single patient using a new, sterile lancets must never be reused. or vial is reused.7 needle and syringe for every access. Never reuse blood glucose monitors for Never reuse medications packaged as a — Ensure ports and stoppers are dis- more than one patient without clean- single dose vial on more than one patient. infected using friction and a sterile ing and disinfecting the device, washing Reuse of a vial should be limited to single 79% isopropyl alcohol. Alcohol must hands, and changing gloves. There is patients as an extra barrier against unrec- be allowed to dry before each access evidence of risk of patient exposure via ognized contaminated syringe reuse or to ensure proper contact time. indirect transfer of virus from microscopic other means of vial contamination. For — Never store or transport syringes or amounts of blood on a clinician’s hands example, outbreaks linked to multipatient vials in a clinician’s pocket. or gloves after contact with a contami- use of single-dose vials of propofol have nated monitoring device.11 The practice been reported.1 of using blood sugar measuring devices Page 72 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority such as glucometers without cleaning and includes periodic certification or compe- practices, including methods for direct disinfecting between every use creates an tency requirements for all clinicians in observation, staff interviews, short ques- immediate jeopardy to patient health by healthcare facilities.4 Perz et al. described tionnaires, and practice simulations.20 A potentially exposing patients and nursing the following learning objectives to sup- prospective review of an organization’s safe home residents to the spread of blood- port the development of an injection injection practices can be assessed with borne infections.15 Clean and disinfect safety curriculum:7 the World Health Organization Guide glucose monitoring equipment between — Recognize the basics of indirect con- for Supervising Injections worksheet uses and routinely between patients. tact transmission of infectious agents. available at http://infocooperation.org/ Cleaning must precede disinfection, as hss/documents/s15240e/s15240e.pdf. — Detect and correct unsafe practices. some disinfectants are ineffective in the Senior management support for safety presence of soil.16 In the absence of manu- — Describe safe injection and basic programs, frequent safety-related feedback, facturer’s recommendations, noncritical aseptic practices including hand and removal of workplace barriers to medical equipment is disinfected with hygiene, glove changing, and avoid- safe work practices have been shown to an Environmental Protection Agency ance of cross contamination. be significantly related to compliance.21 registered hospital solution with specific — Understand the need for monitoring Administrative measures to assure com- label claims for HBV and HBC. Follow practices related to injection safety pliance with safe injection practices may the recommended solution contact time and basic infection control. include the following:7 for maximum effectiveness against blood- — Recognize the potential consequences — Develop written infection control borne and other pathogens.17 of syringe reuse and other unsafe policies and measures tailored to the Never prepare injectable medications in practices. individual practice setting. a contaminated workspace (e.g., where — Identify CDC infection control — Provide infection control training needles and syringes are dismantled guidelines and educational materials. and at least an annual review of staff and discarded). Any item that could have Educational materials, such as the CDC practices. come in contact with blood or body fluids poster “Some Things Should Not Be — Clearly designate responsibility for should not be in the clean medication Reused,” can be placed in patient waiting oversight and monitoring; include prep area.4 Medication preparation should areas and staff lounges to increase aware- infection control personnel. be restricted to a centralized medication ness of safe injection practices for patients — Establish procedures and responsibili- area, a clear demarcation of clean and dirty and staff.18 CDC through its “The ties for reporting and investigating areas in confined workspaces, and never in One & Only Campaign” website and breaches in infection control policy. the patient treatment or procedure area, other organizations provide a variety of especially in hemodialysis centers.2,4 resources to assist in education, training, — Conduct quality assurance competency evaluations, and monitoring assessments. INCREASING THE AWARENESS (see “Where Can Providers Go for More Administrators can take the lead by send- OF SAFE INJECTION PRACTICES Information?”). ing a letter to clinicians that supports and describes the facility’s safe injection policy A safe injection is one that does not harm and practice expectations22 and by ensur- the recipient, does not expose the provider OVERSIGHT OF COMPLIANCE WITH SAFE INJECTION PRACTICES ing establishment of processes to address to any avoidable risks, and does not result containing, transporting, and handling in waste that is dangerous for the com- A comprehensive approach to manage- patient care equipment that may be con- munity.7 Improved education of healthcare ment of unsafe injection practices should taminated with blood.6 professionals in nursing, medical, and be aimed at assessment of the clinician, vocational schools is urgently needed to the team, the workplace, and the institu- Safe injection system design can be ensure appropriate investment in basic tion as a whole to make the process as safe achieved by adopting a culture of safety infection requirements and to address as possible.19 and system reform to provide clinicians incorrect beliefs about safe injection prac- with both the reminders and the tools Even when new knowledge is discovered to address human variability factors.19 tices.4 Outbreaks identified by CDC and and adequate research is available, there This entails creating an environment in U.S. public health services indicate a lack are many barriers to implementing research which every provider feels empowered to of awareness and understanding of injec- into practice.1 Gurses et al. published a take responsibility to stop any colleague tion safety and application of basic aseptic template that helps healthcare facilities from engaging in unsafe practices.1 techniques.2 Reinforcement of training identify barriers to implementation of safe While healthcare workers may witness Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 73 ©2011 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION unsafe actions, they often are not com- WHERE CAN PROVIDERS GO FOR MORE INFORMATION? fortable speaking up for patient safety. Examples of employee talking points ASC Quality Collaboration for safe injection practices are described Safe Injection Practices Toolkit in a CDC video transcript available at http://www.ascquality.org/SafeInjectionPracticesToolkit.cfm http://www.oneandonlycampaign.org/ Post/sections/36/Files/SIPC%20-%20 American Society of Consultant Pharmacists (ASCP) FINAL%20VIDEO%20SCRIPT.pdf. ASCP Summary of New Surveyor Guidance on Infection Control at F-Tag 441 http://www.ascp.com/resources/nhsurvey/upload/FTag%20441%20summary.pdf Adopting principles from human factors engineering includes redesigning devices, ASCP’s Summary of Glucometer Cleaning Guidelines equipment, and processes to reduce or http://www.ascp.com/sites/default/files/GlucometerInfectionControl-rev.pdf eliminate the risk of bloodborne patho- gen transmission (e.g., using autodestruct Association for Professionals in Infection Control and Epidemiology (APIC) syringes that make it easy for staff to comply APIC Position Paper: Safe Injection, Infusion and Medication with using a syringe and needle only once).1 Vial Practices in Healthcare http://www.ascquality.org/Library/safeinjectionpracticestoolkit/Safe%20Injection%20 CONCLUSION Infusion%20and%20Medication%20Vial%20Practices%20in%20Healthcare%20 CDC and U.S. public health officials (APIC).pdf have identified 51 outbreaks of HBV Centers for Disease Control and Prevention and HCV infection in the United States 2007 Guideline for Isolation Precautions: Preventing Transmission of associated with unsafe injection practices, Infectious Agents in Healthcare Settings and 620 of 75,000 exposed patients http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/isolation2007.pdf became infected or died with HBV or HCV from 1998 through 2009. Prevent- The One & Only Campaign ing the spread of bloodborne pathogens http://www.cdc.gov/injectionsafety/1anOnly.html represents a basic expectation anywhere healthcare is provided. Healthcare pro- Georgia Association of Nurse Anesthetists viders’ awareness, understanding, and Safe Practices for Needle and Syringe Use [discussion of American Association of implementation of well-established safe Nurse Anesthetists’ position statement] injection practices remain suboptimal. http://www.gana.org/documents/1241559948.pdf The occurrence of outbreaks indicates an urgent need for a multifaceted approach World Health Organization (WHO) focusing on improved education, surveil- WHO Best Practices for Injections and Related Procedures Toolkit lance, oversight, enforcement, and safely http://whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf engineered technologies aimed at ensur- ing safe injection practices at all levels of healthcare delivery.1 NOTES 1. Pugliese G, Gosnell C, Bartley JM, et al. infection outbreaks in healthcare settings, the need for safe injection practices and Injection practices among clinicians in 2008-2009: opening our eyes to viral hepa- basic infection control. Clin Liver Dis 2010 United States health care settings. Am J titis as a healthcare-associated infection. Feb;14(1):137-51. Infect Control 2010 Dec(10);38:789-98. Presented at: Fifth Decennial International 5. Trepanier CA, Lessard Mr, Brochu JG, 2. Thompson ND, Perz JF, Moorman AC, Conference on Healthcare-Associated et al. Risk of cross-infection related to the et al. Nonhospital health care-associated Infections; 2010 Mar 18-22; Atlanta (GA) multiple use of disposable syringes. Can J hepatitis B and C virus transmission: [online]. [cited 2011 Jan 19]. Available Anaesth 1990 Mar;37(2):156-9. United States, 1998-2008. Ann Intern Med from Internet: http://shea.confex.com/ 6. Siegel JD, Rhinehart E, Jackson M, et al. 2009 Jan 6;150(1):33-9. shea/2010/webprogram/Paper1744.html. 2007 guideline for isolation precautions: 3. Thompson ND, Schaefer M, Sharapov U, 4. Perz JF, Thompson ND, Schaefer MK, preventing transmission of infectious et al. A review of hepatitis B and C virus et al. US outbreak investigations highlight Page 74 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority agents in healthcare settings. Am J Infect new paradigm in testing glucose. J Diabe- 2008. [cited 2011 Jan 18]. Available from Control 2007 Dec;35(10 Suppl 2):S65-164. tes Sci Technol 2010 Sep;4(5):1027-31. Internet: http://www.premierinc.com/ 7. Perz J, Srinivasan A, Patel P. COCA 12. Centers for Disease Control and Preven- safety/topics/guidelines/downloads/ conference call: a “never” event: unsafe tion. Hepatitis B facts for the public. Disinfection_Nov_2008.pdf. injection practices [transcript online]. 2009 Jun 9 [cited 2011 Feb 23]. Available 17. Centers for Disease Control and Preven- 2008 Mar [cited 2011 Jan 18]. Available from Internet: http://www.cdc.gov/ tion. Guideline for environmental infection from Internet: http://emergency.cdc.gov/ hepatitis/B/bFAQ.htm. control in health-care facilities [online]. coca/summaries/COCA-UnsafeInjection- 13. Kamili S, Krawczynski K, McCaustland 2003 [cited 2011 Jan 18]. Available from Practices.asp. K, et al. Infectivity of hepatitis C virus in Internet: http://www.premierinc.com/ 8. Dolan SA, Felizardo G, Barnes S, et al. plasma after drying and storing at room safety/topics/guidelines/downloads/ APIC position paper: safe injection, temperature. Infect Control Hosp Epidemiol cdc-guide-environ-ic-12-03-03.pdf. infusion, and medication vial practices 2007 May;28(5):519-24. 18. Centers for Disease Control and Preven- in health care. Am J Infect Control 2010 14. U.S. Food and Drug Administration tion. The one & only campaign. 2011 Apr;38(3):167-72. (FDA). Information for healthcare Feb 9. [cited 2011 Feb 23]. Available 9. Centers for Disease Control and professionals: risk of transmission of from Internet: http://www.cdc.gov/ Prevention. Workbook for designing, blood-borne pathogens from shared use injectionsafety/1anOnly.html. implementing, and evaluating a sharps of insulin pens. [FDA alert online]. 2009 19. Reason J. Human error: models and man- injury prevention program. [cited 2011 Mar. [cited 2011 Jan 18]. Available from agement. BMJ 2000 Mar 18;320:768-70. March 29]. Available from Internet: Internet: http://www.fda.gov/Drugs/ 20. Gurses AP, Murphy DJ, Martinez EA, http://www.cdc.gov/sharpssafety/pdf/ DrugSafety/PostmarketDrugSafety et al. A practical tool to identify and sharpsworkbook_2008.pdf. InformationforPatientsandProviders/ eliminated barriers to compliance with 10. Centers for Disease Control and Preven- DrugSafetyInformationforHeathcare evidence-based guidelines. Jt Comm J Qual tion. Transmission of hepatitis B virus Professionals/ucm133352.htm. Patient Saf 2009 Oct;35(10):526-32. among persons undergoing blood glucose 15. Unites States Centers for Medicare and 21. Gershon RR, Karkashian CD, Grosch monitoring in long-term-care facilities— Medicaid Services. §483.65(b): preventing JW, et al. Hospital safety climate and its Mississippi, North Carolina, and Los spread of infection interpretive guidelines relationship with safe work practices and Angeles County, California, 2003-2004 F-tag 441 [memo online]. [cited 2011 Jan workplace exposure incidents. Am J Infect [online]. MMWR 2005 Mar 11 [cited 18]. Available from Internet: http://www. Control 2000 Jun 28(3):211-21. 2011 Jan 18]. Available from Internet: cms.gov/SurveyCertificationGenInfo/ 22. ASC Quality Collaboration. Safe injec- http://www.cdc.gov/mmwr/preview/ downloads/SCLetter09_54.pdf. tion practices toolkit [online]. [cited 2011 mmwrhtml/mm5409a2.htm. 16. Rutala WA, Weber DJ. Healthcare Jan 18]. Available from Internet: 11. Klonoff DC, Perz JF. Assisted monitoring Infection Control Practices Advisory http://www.ascquality.org/ of blood glucose: special safety needs for a Committee. Guideline for disinfection SafeInjectionPracticesToolkit.cfm. and sterilization in healthcare facilities, LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Distinguish between safe and unsafe The following questions about this article may be useful for internal education and injection practices. assessment. You may use the following examples or develop your own questions. — Recognize misperceptions associated Case Scenario with unsafe injection practices. While making rounds, the facility patient safety officer notices the following practices. — Predict consequences of unsafe injec- Patient A was administered his daily dose of insulin using a reusable insulin pen. Then, tion practices. the needle was changed and Patient B was administered his morning dose of insulin. — Identify appropriate approaches to Using a new syringe, intravenous (IV) flush solution was withdrawn from a common integrate safe injection strategies into bag of IV solution to flush two patients’ IV lines and administer IV medication. A clinical practice. second sterile syringe was used to draw a blood specimen on Patient C. 1. The following list includes infection control actions from the above scenario that are and are not associated with unsafe injection practices. Select the action that is not associated with unsafe injection practices. a. Changing the needle on a used syringe or device before injecting medication into more than one person b. Accessing a common bag of sterile intravenous solution to flush IV lines of multiple persons Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 75 ©2011 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION SELF-ASSESSMENT QUESTIONS (CONTINUED) c. Wiping the glucometer with a disinfectant between using it to test blood sugar levels on multiple patients d. Preparing intravenous medication in the dialysis patient treatment area 2. Which statement least accurately describes the misperceptions associated with unsafe injection practices? a. The risk for syringe contamination in an IV line is eliminated by distance, gravity, and positive infusion pressure. b. Reusing a syringe for additional doses of medication for the same patient is safe. c. Secondary use of a syringe is safe because contamination is limited to the needle device. d. Preparation of injectable medications is appropriate in a confined workspace with a clear demarcation of clean and dirty areas. Continued Scenario In preparation for a surgical intervention on Patient A, the certified registered nurse anesthetist combined the contents of a used bottle of propofol from an earlier case with another partially used vial stored in his lab coat pocket, then administered propofol from that vial using a clean needle attached to the syringe from the previous case. The certified registered nurse anesthetist flushed the IV and used a new syringe and needle to draw a blood specimen. A new syringe and needle were inserted into the vial of propo- fol, and this was placed on the anesthesia table in preparation for the next case. During an investigation of an outbreak of hepatitis, both patients were subsequently diagnosed with new hepatitis C infections. 3. The following practices are evident in the above scenario. Select the process that will not contribute to contamination of injection equipment and medication vials. a. Administering propofol from the contents of a combined vial stored in a lab coat pocket b. Using a second syringe to draw a blood specimen after flushing an IV line c. Accessing a vial of medication with a clean needle using a syringe from a previ- ous case d. Inserting a fresh needle and syringe into a medication vial and storing this on the anesthesia table for the next case 4. Which of the following system-level interventions would not be appropriate to pre- vent unsafe injection practices? a. Develop protocol to change needles on all syringes used for multiple patients. b. Unpackage syringes as close to administration time as possible. c. Purchase single dose medication and flush vials whenever possible. d. Label individual insulin pen devices for each patient using them. 5. Which of the following strategies is the most appropriate regarding awareness and oversight of safe injection practices? a. Empower patients to speak up about unsafe injection practice for patients. b. Write a policy outlining safe injection practice requirements. c. Require periodic injection practice education, competence assessment, and monitoring for all clinicians in healthcare facilities. d. Present a business plan to the chief executive officer supporting the facility’s safe injection policy. Page 76 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 2—June 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.