TJC Advises on Infections Linked to Misuse of Vials
The potential adverse effects of unsafe injection practices are not typically seen immediately, but can have catastrophic consequences for patients and for providers, says The Joint Commission.
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The Joint Commission, in its latest Sentinel Event Alert, is warning healthcare providers that serious blood-borne and bacterial infections are among the consequences of misusing single-dose/single-use and multiple-dose vials.
Thousands of patients have been adversely affected by misuse of contaminated vials, The Joint Commission reports. It cites information from the Centers for Disease Control, which has tracked at least 49 outbreaks since 2001 due to incorrectly administered injectable medical products. Of those, 21 involved the transmission of hepatitis B or C; the other 28 were outbreaks of bacterial infections.
Since 2007, nineteen outbreaks have been caused by the misuse of single-dose vials. Seven were blood-borne pathogen infections; 12 were bacterial infections. All outbreaks occurred in outpatient settings; eight were in pain remediation clinics.
Another recent study by the CDC and Centers for Medicare & Medicaid Services found that two-thirds of ambulatory surgical centers had lapses in basic infection control practices. Twenty eight percent of those surgical centers also reused single-dose vials on multiple patients.
A major contributing factor to the misuse of vials is widespread lack of adherence to safe injection practices. For example, the misuse of vials frequently involves healthcare workers reusing single-dose vials. As single-dose vials usually lack preservatives, they can easily foster bacterial growth between uses.