Unsafe Injection Practices: Outbreaks, Incidents, and Root Causes

From Medscape Education Infectious Diseases

David Pegues, MD; Karen Hoffman, RN, MS; Joseph Perz, DrPH, MA; Robin Stackhouse, MD

07/12/2011; 

What happens when safe injection practices are not followed?

The literature is replete with examples of dramatic outbreak investigations. 

It's estimated that more than 125,000 people, including patients and their loved ones, have been notified and stressed, to say the least, as a result of dozens of incidents of potential exposure to blood-borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. 

In addition, potential exposures to bacterial pathogens have occurred, including bloodstream infections and meningitis, with significant health consequences, and there has been at least 1 parasitic outbreak investigation. 

One of the central issues to safe injection practice is that syringe reuse is inherently dangerous, so we like to say that syringe reuse represents low-hanging fruit in regard to prevention.

Direct syringe reuse is when a syringe is used for more than 1 patient.  

Another example of an outbreak resulting from direct syringe reuse occurred in a hospital-based pain clinic in Oklahoma in 2002. The staff prefilled syringes with fentanyl and propofol to treat multiple patients. It seemed like a good idea, but they reused the syringes through heparin locks, which they thought was the safety factor, into the intravenous lines. This breach resulted in a large number of infections: 71 cases of HCV infection and 31 cases of HBV infection.

It's not just the number of patients infected, but the hundreds, sometimes tens of thousands, of patients who require notification and who must live with uncertainty while awaiting their test results.
Imagine as a parent being notified that your child was potentially exposed to blood-borne viruses while receiving routine medical care.
It's the nature of hepatitis as well as HIV infections. There is an incubation period with the hepatitis viruses and HIV. If someone was exposed last week, it will take many months to rule out an infection. Healthcare workers go through this when they suffer a needle stick. This weighs heavily on patients who receive letters of notification about potential exposures.

Let's talk about contamination of a shared medication vial that occurs as a result of indirect syringe reuse. Indirect syringe reuse occurs when the same syringe used to administer medication to a patient is used to withdraw additional medications from vials for the same patient.
Those medication vials can become contaminated and serve as a source of infection to any patients who are administered medications from those vials. We also refer to this as "double dipping."

The outbreak in an outpatient endoscopy center in Nevada is a good example. This involved administration of a sedative in an outpatient setting. Anesthesia providers reused syringes to reenter vials of propofol. It's interesting that there was some perception of risk because these providers changed the needles on the syringes. A common misperception is that contamination is limited to the needle, representing a failure to appreciate that the needle and syringe are a contiguous unit and that the syringe can be contaminated in the process of injecting a patient with medication.
It's also important to note that contamination of the needle, and subsequently the syringe, can occur in the absence of obvious blood contamination. Another misperception is that if you can't see blood in the syringe, it doesn't contain a blood-borne pathogen.
Single-dose vials do not routinely contain a preservative or antiseptic, and although they're not intended for use in multiple patients, contamination does occur and contributes to the transmission of bacterial pathogens.

The fundamental take-home points about safe injection practices:-

• First, it's important for providers to remember that needles and syringes are single-use devices. This isn't new, but it's something that we all need to understand and practice. Needles and syringes should not be used for more than 1 patient or be reused to draw up additional medication. Changing needles does not offer additional protection. If anything, it puts providers at risk.
• Second, if we limit the sharing of medications, we can better achieve the double layer of protection. To that end, it's important to remind providers that we must not administer medications from a single-dose vial or bag of intravenous solution to multiple patients.
• Third, we should attempt to limit the use of all shared medications, including vials that are approved and labeled by the US Food and Drug Administration as multidose vials. Ideally, we should use vials in the smallest quantity appropriate for a given clinical application.