Evelyn McKnight, AuD, has first-hand knowledge of the devastating consequences of unsafe injection practices. In 2001, she contracted hepatitis C while undergoing chemotherapy for breast cancer.

An investigation into the source of Dr. McKnight’s infection by the state health department and Centers for Disease Control and Prevention (CDC) uncovered “dumbfounding and unsettling” findings, she said. For 16 months, a clinic nurse had been reusing syringes to draw saline solution from a common IV bag during port-flushing procedures in advance of administering chemotherapy. In the process, hepatitis C virus (HCV) infection from a previously infected patient was spread to 99 others.

“The irony is that I traded one life-threatening disease for another,” Dr. McKnight, founder of HONOReform Foundation, a national advocacy organization dedicated to safeguarding injection practices, said during a recent Institute for Safe Medication Practices (ISMP) webinar.

Matthew Fricker, RPh, MS, a program director at ISMP, said he worries that outbreaks like the one Dr. McKnight was involved in are only the tip of the iceberg and many others remain unreported.

Results from the 2011 ISMP Medication Safety Self Assessment for Hospitals support this concern, he said. Of the more than 1,300 hospitals that completed the assessment, 2% had not implemented any policy prohibiting the use of multiple-dose vials for saline and heparin flush solutions or for local anesthetics, and 24% had only partially implemented such a policy. Two percent had only partially implemented a hospital-wide policy prohibiting the reuse of the same syringe in more than one patient even if the needle had been changed between patients.

According to Mr. Fricker, 2% may seem like an insignificant number, but when it comes to injection practices, small mistakes can have significant consequences. “We need to be at 100% adherence for these practices,” he emphasized.

Recent reports of insulin pens being reused—including one reported shortly after the webinar (Whitman V. “Catskill hospital warns that insulin pens may have been reused,” Times Herald-Record, May 21, 2013)—have placed nearly 5,000 patients at risk for HIV, hepatitis B virus (HBV) or HCV infections, Mr. Fricker noted. In the ISMP hospital assessment, 9% of hospitals said they had not taken any formal steps to implement a policy prohibiting the use of multidose pens as unit stock.

The misuse of insulin pens has prompted the ISMP to recommend that hospitals consider transitioning away from using pen devices. “Issuing this recommendation was not a decision we made lightly,” Mr. Fricker said.

A look at the outbreak of HCV that occurred in Las Vegas in 2008 illustrates how reuse of syringes and single-dose vials can lead to rapid exposure to infectious diseases in large numbers of individuals, Joseph Perz, DrPH, a team leader in Ambulatory and Long-Term Care in the Prevention and Response Branch at the CDC’s Division of Healthcare Quality Promotion, told webinar attendees.

That outbreak started with a clean needle and syringe that had initially been used to draw from a single-use vial and administer the medication to an HCV-infected patient. Backflow from the injection or from the removal of the needle contaminated the syringe, which was then reused to draw medication from the single-use vial, contaminating the vial and initiating a chain of infection transmission.

“What happened there was not unique to Vegas,” Dr. Perz said during the webinar. “We see this over and over.”

Need for Education
Dr. Perz said he believes that many of these lapses in safe practice are due to a lack of understanding as to what constitutes safe injection practices. “To even get nurses to recognize the da ifference between a single- and multiple-dose vial requires significant effort,” Dr. Perz told ISMP webinar attendees. “We need to train our providers just to read the label. Unless it is a manufactured vial with the term ‘multidose vial’ printed on it, it is not a multidose vial.”

Results from a 2010 survey of 5,000 health care workers, most of whom were nurses, illustrates the disparity between how well clinicians believe they are doing in preventing infections and how they behave, Mr. Fricker said (Am J Infect Control 2010;38:789-798). Although most respondents said they followed recommended infection control practices, 6% said they sometimes or always used single-dose vials for multiple patients and 1% said they reused a syringe for more than one patient after discarding the needle.

“There is a misconception that changing a needle is enough to be safe,” Mr. Fricker said. “Many of these respondents were unaware of the risk for spreading disease after changing a needle but reusing the same vial.”
Dr. Perz urged webinar attendees to share the CDC’s Injection Safety Checklist (www.cdc.gov/injectionsafety) and to visit ONEandONLYcampaign.org for free staff training activities, brief how-to videos and posters emphasizing the importance of using single-dose vials and insulin pens in only one individual.

Dr. Perz concluded, “I don’t think we can do enough to educate providers on what safe practices are.”