Joint Commission warns against misuse of vials


Thousands of patients have been adversely affected by the misuse of single-dose/single use and multiple dose vials, according to a Sentinel Event Alert released on Monday by the Joint Commission.

“The misuse of these vials has caused harm to individual patients through occurrences and outbreaks of bloodbourne pathogens and associated infections, including hepatitis B and C virus, meningitis and epidural abscesses,” it stated.

According to the Joint Commission, the misuse of vials primarily involves the reuse of single-dose vials, which are intended to be used once for a single patient. Single-dose vials typically lack preservatives; therefore, using these vials more than once carries substantial risks for bacterial contamination, growth and infection.

Since 2001, at least 49 outbreaks have occurred due to the mishandling of injectable medical products, according to the CDC. Twenty-one of these outbreaks involved the transmission of hepatitis B or C; the other 28 were outbreaks of bacterial infections, primarily invasive bloodstream infections.

While many of these outbreaks occurred in inpatient settings, a high percentage occurred in pain management clinics, where injections are often 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 immuno-compromised.

In addition, more than 150,000 patients required notification during this time to undergo bloodbourne pathogen testing after their potential exposure to unsafe injections.

According to the Joint Commission’s alert, a significant contributing factor to the misuse of vials is the lack of adherence to safe infection control practices and to aseptic techniques within healthcare organizations.

For example, a survey of 5,446 healthcare practitioners found that for single-dose/single-use vials, 6 percent admitted to sometimes or always using vials for multiple patients. For multiple-use vials, 15 percent reported using the same syringe to re-enter a vial numerous times for the same patient and of that 15 percent, 6.5 percent reported saving vials for use on another patient.

The Joint Commission recommends the development and implementation of effective evidence-based organization-wide standardized policy and procedures for the prevention of misuse of vials.

It also recommends annual education on injection safety and on preventing the misuse of vials for all staff who administer injections, including new or temporary staff.

“Staff education should reduce staff tolerance of behavioural choices that may place patients or others at risk of harm, such as using a single-dose vial of medication for multiple patients,” it added.

It also emphasized the importance of a safety culture.“Emphasize that all staff are responsible for reporting risks, errors (including near misses) and adverse events,” it stated. “Create a culture within which the reporting of unsafe injection and infection control practices or near misses is viewed as a necessary step to improve safety.”

Joint Commission, Sentinel Event Alert, US