The number of patients involved in each ranged from as few as 25 who were injected with an influenza vaccine with a syringe that had been reused between patients in New York, to 8,690 ambulatory surgical center and hospital patients in Colorado and New York who received fentanyl from a provider who had reused syringes, to 63,000 patients of ambulatory surgical centers (single purpose endoscopy clinics), who received propofol through syringes that contaminated medication vials in Las Vegas, NV.
Nearly two-thirds of the events involved identified hepatitis B or hepatitis C transmission. "The primary breach implicated was accessing shared injectable medications with reused syringes (at least 16 notification events)," their report said. "However, overt reuse of syringes or insulin pens from one patient to another was also identified (at least 12 notification events), including the reuse of prefilled syringes to administer influenza vaccine or botulinum toxin."
The substances in the syringes ranged from saline flush and vitamin C and B12 to lidocaine, insulin and unspecified anesthesia medications.
Guhn says that officials for the CDC and various state health agencies that investigated the incidents "were surprised at the magnitude of patients who were potentially exposed," however she quickly added that it was not a surprise in terms of knowing that unsafe injection practices have occurred, and still occur today."
Several national campaigns, such as the CDC's "One and Only," are under way to educate healthcare providers about safe practices. And last July, the CDC launched an Ambulatory Care Safety campaign and Healthcare Provider Toolkit.