An infection spread by unsafe injection practices can happen anywhere. In 2008, it happened at an endoscopy clinic in Las Vegas. When a patient infected with hepatitis C was injected with propofol from a single-dose vial, backflow contaminated the syringe. Nurses reused the syringe to draw additional medication from the vial after replacing the needle. By placing the reused syringe in contact with the vial, they contaminated the vial. The routine reuse of single-dose vials for multiple patients resulted in an outbreak of hepatitis C.

Joseph Perz, DrPH, a health care epidemiologist at the Centers for Disease Control and Prevention (CDC) in Atlanta, recounted the story of the Las Vegas outbreak in a Nov. 13 CDC webinar, “Unsafe Injection Practices in the U.S. Healthcare System.” Since 2001, Dr. Perz said, at least 48 outbreaks caused by unsafe injection practices have occurred in the United States, with the majority (90%) in outpatient settings (10 in pain clinics and nine in oncology clinics). Twenty-one of the outbreaks involved hepatitis B or hepatitis C; 27 were bacterial. More than 150,000 patients required notification to recommend bloodborne pathogen testing following exposure to unsafe injections.

Dr. Perz noted that contamination can occur with syringes as well as other medication containers. For example, he noted that syringes can be reused indirectly, as in the Las Vegas case, in which a reused syringe contaminated a vial, or directly, in which a single syringe is used for several patients. Insulin pens also can be reused mistakenly, causing contamination. For example, it was reported in January that insulin pens may have been reused unintentionally in more than 700 patients at the Buffalo Veterans Affairs Medical Center, possibly exposing the patients to HIV, hepatitis B and/or hepatitis C.

Another potential problem occurs when a single-dose vial is used for multiple patients. Because the single-dose vials typically lack preservatives, this practice carries risks for bacterial contamination. IV bags also are often mistakenly used as a common source of supply for multiple patients. “Another concern is that clinical staff may spike, or prepare, batches of IV bags, or draw multiple syringes out of vials, and hold them indefinitely although they are preservative-free,” Dr. Perz told Pharmacy Practice News.

Darryl S. Rich, PharmD, MBA, FASHP, medication safety specialist, Institute for Safe Medication Practices (ISMP), in Horsham, Pa., who was not associated with the CDC webinar, said, “The most egregious [unsafe injection practice] is the reuse of the same syringe. That is probably the top in causing infections. Also egregious is using single-dose vials for multiple patients.”

Multiple-dose vials also can be associated with contamination, Dr. Rich said. “A CDC safe injection practice is that a multiple-dose vial should not be opened and stored in the immediate patient treatment area,” said Dr. Rich. “If it is, it should be used only for one patient and then discarded. A lot of hospitals don’t agree with this particular guideline because of the cost involved. CDC has evidence that these vials in close contact to patients can cause cross-contamination, so I think it makes sense. It takes a little creative thinking. See if there are areas to draw up doses from multidose vials farther from the patient. Use single-dose vials instead of multidose vials. The best approach is to use prefilled syringes drawn up using automation in the pharmacy or prepared from an operating room satellite.”

The Safe Injection Practices Coalition—a partnership of health care–related organizations that includes the CDC and ISMP—is leading an effort to raise awareness about safe injection practices. The slogan of the coalition’s One & Only Campaign, is: “One needle, one syringe, only one time.” The message is meant to be clear and to the point. “We do not want any health care provider telling us they didn’t know better when it comes to syringe reuse and other unsafe injection practices,” Dr. Perz noted.


Among the campaign’s resources is an injection safety checklist that providers can use to assess adherence to safe injection practices (Figure). “The injection safety checklist is meant for providers to stop [and] take a moment to examine their practices, that of their staff and peers,” Dr. Perz said. Campaign staff recently launched additional new materials, including an animated video, a podcast, posters and a bloodborne pathogens training activity (​news/​new-​tools-​help-​clinicians-​ensure-​every-​injection-safe).

Pharmacists Need To Be Part of Team Effort

Pharmacists have an important role to play in ensuring safe injection practices, stressed Dr. Perz. “Pharmacists are in a good position to understand how important it is to maintain sterility of injectable medications. The pharmacists’ vigilance can extend to the point of care, to ensure safe and appropriate use of dispensed medication products.”

“If there’s a shortage, the pharmacy should break the drug in large single-dose vials down into individual units,” Dr. Rich said. “The pharmacist needs to work with the infection control coordinator. It’s a team effort.”

Dr. Perz suggested three “E’s” for ensuring safe injections: “Epidemiologic capacities and resources,” “Educational initiatives,” and “Enforcement and oversight.” Pharmacists, he said, have a role in all three: recognizing patterns and opportunities for prevention (epidemiology), educating providers about appropriate practice (education), and participating in walkthroughs and audits (enforcement).

A study published Dec. 10 online in American Health & Drug Benefits delineated the effects of preventable adverse drug events (ADEs), such as those caused by unsafe injection practices. The study, commissioned by BD, showed that such ADEs affect more than 1 million hospitalized patients and cost $2.7 billion to $5.1 billion annually.

—Additional reporting by Sarah Tilyou

Drs. Perz and Rich reported no relevant financial conflicts of interest.